Great Insurance Solutions (Auto)

1
Referred by:Skip, if none.
2
Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
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Australia
Austria
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The Bahamas
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Brazil
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Burundi
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Canada
Cape Verde
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Chile
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Cote d'Ivoire
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Cuba
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Denmark
Djibouti
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Dominican Republic
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Egypt
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Equatorial Guinea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
Saint Martin
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Samoa
San Marino
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Saudi Arabia
Senegal
Serbia
Seychelles
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Slovenia
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South Sudan
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Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email* This field is required.
example@example.com
5
Phone Number
Please enter a valid phone number.
6
Number of Vehicles* This field is required.
7
Vehicle Number 1
8
Model Year* This field is required.
9
Vehicle Make* This field is required.
ex. TOYOTA
10
Vehicle Model* This field is required.
ex. COROLLA
11
Year Vehicle Acquired
12
Vehicle Usage
Pleasure
Commute
13
If Commute, state number of kilometres
Number of Kilometres ONE WAY
Number of Kilometres ANNUALLY
14
VIN Number* This field is required.
15
Number of Drivers for this Vehicle?* This field is required.
1
2
3
4
5
16
Primary Driver Information 1
17
Name* This field is required.
First Name
Last Name
18
Driver's Licence Number* This field is required.
19
Date of First Licence in Canada* This field is required.
20
Licence Class* This field is required.
G1
G2
Full G
Other
21
Do You Have a Driver's Training Certificate?
Yes
No
22
Attach Driver's Training Certificate Here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
23
Number of Convictions within the last 3 years* This field is required.Type N/A if none.
Skip if not applicable
24
Date of 1st Conviction* This field is required.
Date
Month
Day
Year
25
Type of 1st Conviction* This field is required.
26
Date of 2nd Conviction* This field is required.
Date
Month
Day
Year
27
Type of 2nd Conviction* This field is required.
28
Date of 3rd Conviction* This field is required.
Date
Month
Day
Year
29
Type of 3rd Conviction* This field is required.
30
Licence Suspension within last 6 years?* This field is required.
Yes
No
31
If yes, date of suspension.* This field is required.
Date
Month
Day
Year
32
Reason for Suspension* This field is required.
33
Number of claims in the past 6 years
34
Number of "At Fault Accidents" within last 6 yrs?* This field is required.
Skip, If none.
35
Date of 1st Claim* This field is required.
Date
Month
Day
Year
36
Kind of Loss* This field is required.
37
Date of 2nd Claim* This field is required.
Date
Month
Day
Year
38
Kind of Loss* This field is required.
39
Date of 3rd Claim* This field is required.
Date
Month
Day
Year
40
Kind of Loss* This field is required.
41
Previous Insurance?* This field is required.
YES
No
42
Insurance Company
43
Expiry Date
Date
Month
Day
Year
44
Policy Number
45
Vehicle Number 2
46
Model Year* This field is required.
47
Vehicle Make* This field is required.
ex. TOYOTA
48
Vehicle Model* This field is required.
ex. COROLLA
49
Year Vehicle 2 was acquired
50
Vehicle Usage
Pleasure
Commute
51
If Commute, state number of kilometres
Number of Kilometres ONE WAY
Number of Kilometres ANNUALLY
52
VIN Number* This field is required.
53
Number of Drivers for this Vehicle?* This field is required.
1
2
3
4
5
54
Primary Driver Information 2
55
Name* This field is required.
First Name
Last Name
56
Driver's Licence Number* This field is required.
57
Date of First Licence in Canada* This field is required.
58
Licence Class* This field is required.
G1
G2
Full G
Other
59
Do You Have a Driver's Training Certificate?
Yes
No
60
Attach Driver's Training Certificate Here.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
61
Number of Convictions within the last 3 years* This field is required.Type N/A if none.
Skip if not applicable
62
Date of 1st Conviction
Date
Month
Day
Year
63
Type of 1st Conviction
64
Date of 2nd Conviction
Date
Month
Day
Year
65
Type of 2nd Conviction
66
Date of 3rd Conviction
Date
Month
Day
Year
67
Type of 3rd Conviction
68
Licence Suspension within last 6 years?* This field is required.
Yes
No
69
If yes, date of suspension.
Date
Month
Day
Year
70
Reason for Suspension
71
Number of "At Fault Accidents" within last 6 yrs?* This field is required.
Skip, If none.
72
Date of 1st Claim* This field is required.
Date
Month
Day
Year
73
Kind of Loss* This field is required.
74
Date of 2nd Claim
Date
Month
Day
Year
75
Kind of Loss
76
Date of 3rd Claim
Date
Month
Day
Year
77
Kind of Loss
78
Previous Insurance?* This field is required.
YES
No
79
Insurance Company
80
Expiry Date
Date
Month
Day
Year
81
Policy Number
82
Vehicle Number 3
83
Model Year
84
Vehicle Make
ex. TOYOTA
85
Vehicle Model
ex. COROLLA
86
Year Vehicle 3 was acquired
87
Vehicle Usage
Pleasure
Commute
88
If Commute, state number of kilometres
Number of Kilometres ONE WAY
Number of Kilometres ANNUALLY
89
VIN Number
90
Number of Drivers for this Vehicle?
1
2
3
4
5
91
Primary Driver Information 3
92
Name
First Name
Last Name
93
Driver's Licence Number
94
Date of First Licence in Canada
95
Licence Class
G1
G2
Full G
Other
96
Do You Have a Driver's Training Certificate?
Yes
No
97
Attach Driver's Training Certificate Here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
98
Number of Convictions within the last 3 years
Skip if not applicable
99
Date of 1st Conviction
Date
Month
Day
Year
100
Type of 1st Conviction
101
Date of 2nd Conviction
Date
Month
Day
Year
102
Type of 2nd Conviction
103
Date of 3rd Conviction
Date
Month
Day
Year
104
Type of 3rd Conviction
105
Licence Suspension within last 6 years?
Yes
No
106
If yes, date of suspension.
Date
Month
Day
Year
107
Reason for Suspension
108
Number of "At Fault Accidents" within last 6 yrs?
Skip, If none.
109
Date of 1st Claim
Date
Month
Day
Year
110
Kind of Loss
111
Date of 2nd Claim
Date
Month
Day
Year
112
Kind of Loss
113
Date of 3rd Claim
Date
Month
Day
Year
114
Kind of Loss
115
Previous Insurance?
YES
No
116
Insurance Company
117
Expiry Date
Date
Month
Day
Year
118
Policy Number
119
Which other types of Insurance do you have?* This field is required.
Home Insurance
Boat Insurance
Other
120
Additional Notes
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: