How did you hear about us? |
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Name: |
(required) |
Address: |
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City: |
(required) |
Province: |
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Postal Code: |
(required) |
Phone Number: |
(required) |
Email Address: |
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Preferred Method of Contact: |
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Have you ever had insurance cancelled or refused: |
Yes
No |
Is your car currently insured: |
Yes
No |
If not, have you had insurance for 12 consecutive months within the last 6 years: |
Yes
No |
When should coverage start : |
(dd/mm/yyyy) |
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Driver(s) Information: |
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Name: |
#1
#2 |
#3 |
Date of Birth: |
#1
#2 |
#3 |
Years licensed in Canada: |
#1
#2 |
#3 |
License Class: |
#1
#2 |
#3 |
Sex: |
#1
#2
#3 |
Marital Status: |
#1
#2 |
#3 |
Drivers Training: |
#1
#2
#3 |
Retired: |
#1
#2
#3 |
Minor traffic convictions in the last 3 years: |
#1
#2 |
#3 |
Major traffic convictions in last 3 yrs (careless, impaired etc): |
#1
#2 |
#3 |
Name of current insurance company: |
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Have any of above drivers had their licenses suspended or lapsed in past 6 years: |
Yes
No |
Have any of the drivers above had accidents / claims in past 10 yrs: |
Yes
No |
Claims Information: |
Claims |
Date
(mm/yyyy) |
#1:
#2:
#3: |
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Vehicle Information: |
Vehicle #1 |
Vehicle #2 |
Vehicle make: |
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Year: |
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Model: |
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VIN number (optional): |
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Style: |
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Use: |
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KM driven one way to work: |
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Who is primary driver: |
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Coverage Required: |
Vehicle #1 |
Vehicle #2 |
Liability: |
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Collision deductible: |
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Comprehensive deductible: |
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Comments: |
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