Insurance Referral Form

Customer Details

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 a copy of which can be found on the
    WBS website at