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Auto Insurance
   
    Name:
    Address:
    City:
    Province:
    Postal Code:
    Phone Number:
    Email Address:
    Have you ever had insurance cancelled or refused?
Yes     No
    Do you currently insure your car?
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:
#1 #2 #3
    Name:
    Age:
    Years licensed in Canada:
    License class:
    Sex:
    Marital status:
    Driving school:
    Retired?
    Minor traffic convictions in the last 3 yrs:
    Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
    Are you currently insured?
Yes     No
    Name of previous insurance company:
    Have any of above drivers had their licenses suspended or lapsed in the past 6 years?
Yes     No
    Have any of the drivers above had accidents or claims in the past 10 years?
Yes     No
    Claims Information:
Claims Date (mm/yyyy) Driver involved
    #1:
    #2:
    #3:
       
    Vehicle Information:
Vehicle #1 Vehicle #2
    Vehicle make:
    Year:
    Model:
    Style:
    Use:
    KM driven one way to work:
    Kilometres driven per year:
    Who is primary driver:
       
    Coverage Required:
Vehicle #1 Vehicle #2
    Liability:
    Collision deductible:
    Comprehensive deductible:
     

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