Auto Insurance Quote

   




City:

Province:

 Postal Code:
 
Phone Number:

Email Address:


Have you ever had insurance cancelled or refused?
Yes    No

If yes, explain:


Do you currently insure your car?
Yes    No

If yes, how long have you continually held the insurance?


Expiry date with present insurer? (dd/mm/yyyy)


If no, how long has it been since you last held insurance?


Driver(s) Information:
#1 #2 #3
Name:
Driver's License #:
Years licensed in Canada:
Date of Birth (dd/mm/yyyy):
License class:
Sex:
Marital status:
Driving school:
Retired?
Minor traffic convictions in the last 3 yrs:
 
Please Explain:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
 
Please Explain:

Are you currently insured?
Yes    No

Name of previous insurance company:

Policy #:

Have any of the above drivers had their licenses suspended or lapsed in the past 6 years?
Yes    No

If yes, explain:

Have any of the drivers above had accidents or claims in the past 10 years?
Yes    No

If yes, explain:

Claims Information:

Claims

Date (mm/yyyy)

Driver involved
#1:
#2:
#3:
   
Vehicle Information:
Vehicle #1 Vehicle #2
Vehicle make:
Year:
Model:
Style:
Use:
Radius of Operation?
KM driven one way to work:
Kilometers driven per year:
Who is primary driver:
   
Coverage Required:
Vehicle #1 Vehicle #2
Liability:
Collision deductible:
No Collision Required No Collision Required
Amount
Comprehensive deductible:
No Comprehensive Required No Comprehensive Required
 
Comprehensive Amount
Comprehensive Amount

Additional Coverage Vehicle 1:

6A Permission to carry passenger for compensation
13C Deletion of glass endorsement
20 Loss of use endorsement
27 Legal liability for damage to non-owned automobile
43R Limited waiver of depreciation
Accident Protection
Other

Additional Coverage Vehicle 2:

6A Permission to carry passenger for compensation
13C Deletion of glass endorsement
20 Loss of use endorsement
27 Legal liability for damage to non-owned automobile
43R Limited waiver of depreciation
Accident Protection
Other
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