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Car Insurance
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Home Insurance
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Business Insurance
Car Insurance
Name:
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Principal Driver Info:
Age:
Sex:
Male
Female
Marital Status:
single
married
common-law
Date licensed
(not inc. “beginners” license):
Secondary Driver Info:
Age:
Sex:
Male
Female
Marital Status:
single
married
common-law
Date licensed
(not inc. “beginners” license):
Do driver(s) under 25 years of age
have driver training certification?
Yes
No
Have you been continuously insured
for the last 3 years? yes
Yes
No
List any claims by any drivers mentioned above in last 6 years:
Driver #
Date (approx)
Type:
1
2
no claims
collision
damage to others only
glass damage
vandalism
fire or theft
1
2
no claims
collision
damage to others only
glass damage
vandalism
fire or theft
1
2
no claims
collision
damage to others only
glass damage
vandalism
fire or theft
Any at fault accidents in
past 6 years?
Yes
No
Any driving convictions in
past 3 years?
Yes
No
List any minor convictions by any drivers listed above in the last 3 years:
Driver #
Date (approx)
Type:
1
2
no convictions
speeding
seat belt
improper stop
vandalism
other
1
2
no convictions
speeding
seat belt
improper stop
vandalism
other
1
2
no convictions
speeding
seat belt
improper stop
vandalism
other
Do any drivers have any major
or criminal code convictions?
Yes
No
Do you use your vehicle for business?
Yes
No
Do any drivers use the vehicle to
commute to and from work?
Yes
No
If yes, approximately how many
kms one way?
Year, make and model of vehicle:
Liability limit requested:
$200 000
$500 000
$1 000 000
$2 000 000
Coverage Preferred:
All perils
Collision
Comprehensive
Specified perils
None
Deductible:
$100
$250
$500
$1000
Additional vehicles to be quoted?
Yes
No
Addition Info:
Disclaimer
