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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 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 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
Claim# Claim 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:
Whom were you referred by?:
 

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