Quotes
Auto Insurance
Property Insurance
Business Insurance
 

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.):
  Have any of above drivers had their licenses suspended or revoked in the past 3 years?
Yes     No
  Have any of the drivers above had accidents or insurance in the past 6 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:
  Kilometres driven per year:
  Who is primary driver:
     
  Coverage Required:
Vehicle #1 Vehicle #2
  Liability:
  Collision deductible:
  Comprehensive deductible:
     
   

Disclaimer