Auto Insurance Form

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Street Address

Street Address Line 2

CityProvince

Postal Code

Please enter a valid phone number.

Previous Insurance Company:
How long with previous company?
Has any insurer cancelled or declined to renew in the last 6 years:   Yes   NoHas any drivers' licenses been suspended or cancelled?   Yes   No
Are any other persons licensed to driver?   Yes   No

If yes to any of the above, please provide details:

Have you had any non-payments of premium in the last 6 years? Yes No*

Accident or Collision claims in the past 10 years? Yes No*
If yes, please provide details:

Tickets or Convictions in the past 3 years? Yes No*
If yes, please provide details:

Have you ever been charged with Impaired or Careless Driving? Yes No*
If yes, please provide details:

Driver 1:   First Name*   Last Name*

Driver License Number:   *
G Date:
G2 Date:
G1 Date:

Driver Training Complete:   Yes   No*

Driver 2:   First Name   Last Name

Driver License Number:
G Date:
G2 Date:
G1 Date:

Driver Training Complete:   Yes   No

Driver 3:   First Name   Last Name

Driver License Number:
G Date:
G2 Date:
G1 Date:

Driver Training Complete:   Yes   No

Driver 4:   First Name   Last Name

Driver License Number:
G Date:
G2 Date:
G1 Date:

Driver Training Complete:   Yes   No

Automobile 1
VIN/Serial Number:
Year:
Make:
Model:
Primary Driver:   First Name   Last Name

Vehicle Use:   Personal Use   Business   Commercial
Please provide number of kms one way for your commute:
What are your annual kms?   Type a label

If you have a business use, please provide percentage of business use:


Own or Lease:   Yes   No
Purchase Date and Price:      Price

Winter Tires:   Yes   No

Coverages
Liability:

Collision Deductible:
Comprehensive Deductible:

OPCF 20:
OPCF 43:

Premium Protection:    Yes   No
Minor Ticket Protection:   Yes   No

List any optional accident benefits you have purchased:

Automobile 2
VIN/Serial Number:
Year:
Make:
Model:
Primary Driver:   First Name   Last Name

Vehicle Use:   Personal Use   Business   Commercial
If for personal use, please provide number of kms one way for your commute:

If you have a business use, please provide percentage of business use:


Own or Lease:   Yes   No
Purchase Date and Price:      Price

Winter Tires:   Yes   No

Automobile 3
VIN/Serial Number:
Year:
Make:
Model:
Primary Driver:   First Name   Last Name

Vehicle Use:   Personal Use   Business   Commercial
If for personal use, please provide number of kms one way for your commute:

If you have a business use, please provide percentage of business use:


Own or Lease:   Yes   No
Purchase Date and Price:      Price

Winter Tires:   Yes   No

Coverages
Liability:
Collision Deductible:
Comprehensive Deductible:

OPCF 20:
OPCF 43:

Premium Protection:    Yes   No
Minor Ticket Protection:   Yes   No

List any optional accident benefits you have purchased:

Automobile 4
VIN/Serial Number:
Year:
Make:
Model:
Primary Driver:   First Name   Last Name

Vehicle Use:   Personal Use   Business   Commercial
If for personal use, please provide number of kms one way for your commute:

If you have a business use, please provide percentage of business use:


Own or Lease:   Yes   No
Purchase Date and Price:      Price

Winter Tires:   Yes   No

How did you hear about us?
Google Search Social Media Community Event/Advertisement Referral (friend/family)) Other*

If Referral or Other please specify: