Quote Request

Quote Request Maker
Request
Preliminary Quote Request

Please complete whatever information you have accessible or would like to provide. Merit will follow-up to support further
For Only Terms Needed for MeritMaster Quote
Merit Existing New Submission for WB
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For Idea of Service Charge, Payment Amount, Rate
Add to CIM Row
New Merit Number
no C
DP Action
Status
Contemplated Payable Amount
Agent Name/ Preparer

First NameLast Name
Brokerage Name or Broker Code
Broker Code Preferred
Requester Email Address
example@example.com
Requester Phone Number

Area CodePhone Number
Customer Names(s)
Personal Name, Any Co-Insured, Or Entity Name
Operating as
Effective Date

MonthDayYear
Inception Date
Expiry Date

MonthDayYear
Final Date of Insurer Time on Risk
Number of Policies
Insurer
Policy 1
Policy Number, if known
Premium Amount
Policy Fee Amount
Insurer
Policy 2
Policy Number, if known 2
Premium Amount 2
Policy Fee Amount 2
Insurer
Policy 3
Policy Number, if known 3
Premium Amount 3
Policy Fee Amount 3
Sum of Premiums and PFs
Province for Tax
Tax Amount
Amount Financed
Number of Pays Requested
DP %
Minimum Retained by Insurer
Pay Plan
Amount Down Payment
Down Payment Amount/ Merit to Collect
APR
Monthly APR
APR as decimal
(1 + r)^n
Numerator
Denominator
Formula Monthly
Total of all pays
Service Charge
Monthly Payment Amount
Flat Rate
QP
Type
Coverage
Policy Term
Street Address
City
Province Abbreviation
two letters
Postal Code
Email of Customer
example@example.com
Telephone Number
Please use no dashes or parenthesis
Service Charge (if, as set out)
Billing Method
Preferred First Pay Date

MonthDayYear
Date
Continuous Plan
use c if CPP
Prior Account Number
Bank
Transit
Acct Number
Urgency/ Date or Time Quote Needed
Upload Dec Page, Preliminary Quote, or Other Documentation

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SIGNATURE

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SIGNATURE

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Signature of Agent or Broker

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Merit Code

MonthDayYear
Date
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Quote Request Maker

Preliminary Quote Request

For Only Terms Needed for MeritMaster Quote

Merit Existing New Submission for WB

Use for a Fast Quote

Add to CIM Row