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Automobile Insurance

* Required Field

Name*:

Address*:

City*:

Province:

Postal Code*:

(X1Y 2Z3)

Phone Number*:

(123-456-7890)

Email Address*:

(xxx@yyyy.zzz)

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

Name of Driver:

Date of Birth:

Drivers Licence#:

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

#1:

Type of Claim:
Date:	(mm/yyyy)
Driver Involved:

#2:

Type of Claim:
Date:	(mm/yyyy)
Driver Involved:

#3:

Type of Claim:
Date:	(mm/yyyy)
Driver Involved:

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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