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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 yes, how long have you continually held the insurance?


Expiry date with present insurer? (dd/mm/yyyy)


If no, how long has it been since you last held insurance?


Driver(s) Information:
#1 #2 #3
Name:
Date of Birth (dd/mm/yyyy):
 
Driver's License #:
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:
If you selected Commercial, what is the use of the vehicles?
 
Radius of Operation?
KM driven one way to work:
 
Kilometers driven per year:
 
Who is primary driver:
   
Coverage Required:
Vehicle #1 Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:
 

Additional Coverage:

6A Permission to carry passenger for compensation
13C Deletion of glass endorsement
20 Loss of use endorsement
27 Legal liability for damage to non-owned automobile
43R Limited waiver of depreciation
Other
 
 



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