Previous Insurance Company: How long with previous company? How many years continuous with auto insurance? Has any insurer cancelled or declined to renew in the last 6 years? If yes, please provide details: Number of automobiles in the household: Number of licensed drivers in the household:
Driver 1: First Name Last Name Date of Birth: Marital Status: Married Common Law Single Gender: Male Female GenX Driver License Number: G Date: G2 Date: G1 Date: Driver Training Complete: Yes No Accident or collision claims in the past 10 years? Yes No If yes, please provide details: Has the driver license ever been suspended or cancelled? Yes No If yes, please provide details: Tickets or convictions in the past 10 years? Yes No If yes, please provide details:
Driver 2: First Name Last Name Date of Birth: Marital Status: Married Common Law Single Gender: Male Female GenX Driver License Number: G Date: G2 Date: G1 Date: Driver Training Complete: Yes No Accident or collision claims in the past 10 years? Yes No If yes, please provide details: Has the driver license ever been suspended or cancelled? Yes No If yes, please provide details: Tickets or convictions in the past 10 years? Yes No If yes, please provide details:
Driver 3: First Name Last Name Date of Birth: Marital Status: Married Common Law Single Gender: Male Female GenX Driver License Number: G Date: G2 Date: G1 Date: Driver Training Complete: Yes No Accident or collision claims in the past 10 years? Yes No If yes, please provide details: Has the driver license ever been suspended or cancelled? Yes No If yes, please provide details: Tickets or convictions in the past 10 years? Yes No If yes, please provide details:
Driver 4: First Name Last Name Date of Birth: Marital Status: Married Common Law Single Gender: Male Female GenX Driver License Number: G Date: G2 Date: G1 Date: Driver Training Complete: Yes No Accident or collision claims in the past 10 years? Yes No If yes, please provide details: Has the driver license ever been suspended or cancelled? Yes No If yes, please provide details: Tickets or convictions in the past 10 years? Yes No If yes, please provide details:
Automobile 1VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Personal Use Business If you have a business use, provide percentage of business use: Commuting to work distance (km one way): Annual kms: Any commercial use? Yes No Own Lease Purchase Date and Price: Price Winter Tires: Yes No
Automobile 2VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Personal Use Business If you have a business use, provide percentage of business use: Commuting to work distance (km one way): Annual kms: Any commercial use? Yes No Own Lease Purchase Date and Price: Price Winter Tires: Yes No
Automobile 3VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Personal Use Business If you have a business use, provide percentage of business use: Commuting to work distance (km one way): Annual kms: Any commercial use? Yes No Own Lease Purchase Date and Price: Price Winter Tires: Yes No
Automobile 4VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Personal Use Business If you have a business use, provide percentage of business use: Commuting to work distance (km one way): Annual kms: Any commercial use? Yes No Own Lease Purchase Date and Price: Price Winter Tires: Yes No
Will any of the vehicles be rented or leased, be used to carry passengers for compensation or hire, be used to carry explosives or radioactive material, used in carpools or other share-the-ride arrangements or be used to haul a trailer? Yes No* If yes to any of the above, please provide details:
Have any of the vehicles been modified or customized or have any unrepaired damage?Yes No* If yes, please provide details: