Maple Leaf Taxi

Insurance Accounts

* Required Information

First Name *	Question Mark First Name of the Authorized Officer
Last Name *	Question Mark Last Name of the Authorized Officer
Company Name *
Street Address *	Question Mark Please enter complete address of the company including any suite numbers.
Postal / Zip Code *
Phone Number *	Question Mark Please specify Extension number e.g 416-000-0000 Ext 123
Email Address *	Question Mark Email address of the authorized officer
Signature *	Question Mark Authorized officers Initial
Company Name Trade Reference 1
Full Name Trade Reference 1
Phone Trade Reference 1	Question Mark Please enter extension number e.g. 416-000-0000 EXT 123
Phone Trade Reference 2	Question Mark Please enter extension number e.g. 416-000-0000 EXT 123
Company Name Trade Reference 2
Full Name Trade Reference 2
Phone Trade Reference 1	Question Mark Please enter extension number e.g. 416-000-0000 EXT 123
Account Details	Question Mark Please mention any important information you think is necessary for Imperial Taxi to know about your requirements.
Agree to Terms and Conditions *	Question Mark Please read the terms and conditions below. Your processing of this application means that you agree with the terms mentioned below.