Driver 1Name: First Name Last Name Date of Birth: Date License Number : Home Address: Street Address Address Line 2 City Province Postal Code License DatesG1: Date G2: Date G: Date Married? Yes No Driver's Training Completion Date: Date Date continuously insured without interruption: Date Years of experience in this type of operation: Driver 2Name: First Name Last Name Date of Birth: Date License Number : Home Address: Street Address Address Line 2 City Province Postal Code License DatesG1: Date G2: Date G: Date Married? Yes No Driver's Training Completion Date: Date Date continuously insured without interruption: Date Years of experience in this type of operation: Driver 3Name: First Name Last Name Date of Birth: Date License Number : Home Address: Street Address Address Line 2 City Province Postal Code License DatesG1: Date G2: Date G: Date Married? Yes No Driver's Training Completion Date: Date Date continuously insured without interruption: Date Years of experience in this type of operation: Driver 4Name: First Name Last Name Date of Birth: Date License Number : Home Address: Street Address Address Line 2 City Province Postal Code License DatesG1: Date G2: Date G: Date Married? Yes No Driver's Training Completion Date: Date Date continuously insured without interruption: Date Years of experience in this type of operation:
Vehicle 1 Year: Date Make: Model: Vin: Purchase Date: Date New Used Demo Use – km one way: Annual km: Vehicle 2 Year: Date Make: Model: Vin: Purchase Date: Date New Used Demo Use – km one way: Annual km: Vehicle 3 Year: Date Make: Model: Vin: Purchase Date: Date New Used Demo Use – km one way: Annual km: Vehicle 4 Year: Date Make: Model: Vin: Purchase Date: Date New Used Demo Use – km one way: Annual km:
Vehicle 1Financed Leased Own If Financed or LeasedName of Company: Address: Street Address Address Line 2 City Province Postal Code Vehicle 2Financed Leased Own If Financed or LeasedName of Company: Address: Street Address Address Line 2 City Province Postal Code Vehicle 3Financed Leased Own If Financed or LeasedName of Company: Address: Street Address Address Line 2 City Province Postal Code Vehicle 4Financed Leased Own If Financed or LeasedName of Company: Address: Street Address Address Line 2 City Province Postal Code
Vehicle 1Primary Driver: First Name Last NameSecondary Driver: First Name Last Name Registered Owner: First Name Last NameVehicle 2Primary Driver: First Name Last NameSecondary Driver: First Name Last Name Registered Owner: First Name Last NameVehicle 3Primary Driver: First Name Last NameSecondary Driver: First Name Last Name Registered Owner: First Name Last NameVehicle 4Primary Driver: First Name Last NameSecondary Driver: First Name Last Name Registered Owner: First Name Last Name
Winter TiresVehicle 1: Yes No Purchase Date:Date Vehicle 2: Yes No Purchase Date:Date Vehicle 3: Yes No Purchase Date:Date Vehicle 4: Yes No Purchase Date:Date
Vehicle 1Street Address Address Line 2 City Province Postal Code Vehicle 2Street Address Address Line 2 City Province Postal Code Vehicle 3Street Address Address Line 2 City Province Postal Code Vehicle 4Street Address Address Line 2 City Province Postal Code
Percentage % of Pleasure UseVehicle 1: Vehicle 2: Vehicle 3: Vehicle 4: Average number of customer locations visited per dayVehicle 1: Vehicle 2: Vehicle 3: Vehicle 4: Normal operating distance - one way Vehicle 1: Vehicle 2: Vehicle 3: Vehicle 4: Percentage % of total trips in this radius Vehicle 1: Vehicle 2: Vehicle 3: Vehicle 4: Maximum operating distance - one way Vehicle 1: Vehicle 2: Vehicle 3: Vehicle 4: Number of trips per month beyond normal radiusVehicle 1: Vehicle 2: Vehicle 3: Vehicle 4: Most Common DestinationsVehicle 1: Vehicle 2: Vehicle 3: Vehicle 4: Any machinery and/or equipment mounted on or attachedYes No Any vehicle used to tow a trailer Yes No Carry explosives, nuclear/radioactive or dangerous goods Yes No Vehicle used for delivery Yes No Hauling done for othersYes No Used for carpoolingYes No Used for ride sharing (Uber, Lyft, etc.) Yes No Any vehicle used for public transportation Yes No Any unrepaired damage Yes No Any modifications or customizations from factory built Yes No Rented or leased to others Yes No Any special/seasonal use (example: snow removal, road salting)Yes No
Please provide destinations: KM to border: Number of trips per month: Number of days: Annual Use %:
Vehicle 1Name of Company: Policy Number: Expiry Date: Date Length of time with driver: Vehicle 2Name of Company: Policy Number: Expiry Date: Date Length of time with driver: Vehicle 3Name of Company: Policy Number: Expiry Date: Date Length of time with driver: Vehicle 4Name of Company: Policy Number: Expiry Date: Date Length of time with driver:
Liability $1million, $2million or higher if offeredVehicle 1: Type a label Vehicle 2: Type a label Vehicle 3: Type a label Vehicle 4: Type a label Collision Deductible $500, $1000 or higher Vehicle 1: Type a label Vehicle 2: Type a label Vehicle 3: Type a label Vehicle 4: Type a label Comprehensive Deductible $500, $1000 or higher Vehicle 1: Type a label Vehicle 2: Type a label Vehicle 3: Type a label Vehicle 4: Type a label
Rental Car CoverageVehicle 1: Yes No Vehicle 2: Yes No Vehicle 3: Yes No Vehicle 4: Yes No
Accident Forgiveness ProtectionVehicle 1: Yes No Vehicle 2: Yes No Vehicle 3: Yes No Vehicle 4: Yes No
Conviction ProtectionDriver 1: Yes No Driver 2: Yes No Driver 3: Yes No Driver 4: Yes No
Increased accident benefits from the included standard Vehicle 1: Yes No Vehicle 2: Yes No Vehicle 3: Yes No Vehicle 4: Yes No
Permission to pull all necessary reports for all driversDriver 1: Yes No Driver 2: Yes No Driver 3: Yes No Driver 4: Yes No