Insurance Application Form

I acknowledge that:

1. I/we have requested information about insurance products or services through Provincial Insurance Brokers
2. I/we have been referred to Provincial Insurance Brokers by WBS;
3. WBS may receive a commission payment from Provincial Insurance Brokers in respect of my/our purchase of any such insurance products or
   services and I/we consent to any such commission payment being made to WBS;
4. WBS will not, other than the information contained on this form, share any of your personal information with Provincial Insurance Brokers,
   without my/our prior consent. WBS manages your personal information in accordance with its Privacy Policy