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Friday 9am - 4pm
Saturday and Sunday by appointment only

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Automobile Quote

How did you hear about us?
Name:	(required)
Address:
City:	(required)
Province:
Postal Code:	(required)
Phone Number:	(required)
Email Address:
Preferred Method of Contact:
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)

Driver(s) Information:
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:
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:
Vehicle Information:	Vehicle #1	Vehicle #2
Vehicle make:
Year:
Model:
VIN number (optional):
Style:
Use:
KM driven one way to work:
Who is primary driver:
Coverage Required:	Vehicle #1	Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:
Comments:

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304 Toronto Street South, Suite #204, Elgin Centre, Uxbridge, ON L9P 1Y2
P: (905) 852-5691 | inquiries@dgsmithinsurance.com | Toll Free: 1-800-377-4784

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