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:
Driver 5: 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 6: 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: Commercial Use Sales Calls If this vehicle will also be used for pleasure, please provide percentage of personal use: Is this vehicle parked at garaging location above at night? Yes No If no, please provide address: Street Address Address Line 2 City Province Postal Code Radius of OperationNormal Operating Distance - One Way: kms % of Total Trips: % Maximum Operating Distance - One way: kms % of Total Trips: % No. of Trips per Month Beyond the Normal Distance from Place Usually Kept: Most Common Destinations - list cities and provinces: Other Uses Is this vehicle used to haul trailers: Yes No Merchandise Carried: Do you do any deliveries: Yes No Do you do any hauling for others: Yes No Is there any U.S.A Exposure: Yes No Is there any machine, equipment or decals mounted on or attached to the vehicle: Yes No If yes, please provide description and value: Do you do any snow removal: Yes No
Automobile 2VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Commercial Use Sales Calls If this vehicle will also be used for pleasure, please provide percentage of personal use: Is this vehicle parked at garaging location above at night? Yes No If no, please provide address: Street Address Address Line 2 City Province Postal Code Radius of OperationNormal Operating Distance - One Way: kms % of Total Trips: % Maximum Operating Distance - One way: kms % of Total Trips: % No. of Trips per Month Beyond the Normal Distance from Place Usually Kept: Most Common Destinations - list cities and provinces: Other Uses Is this vehicle used to haul trailers: Yes No Merchandise Carried: Do you do any deliveries: Yes No Do you do any hauling for others: Yes No Is there any U.S.A Exposure: Yes No Is there any machine, equipment or decals mounted on or attached to the vehicle: Yes No If yes, please provide description and value: Do you do any snow removal: Yes No
Automobile 3VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Commercial Use Sales Calls If this vehicle will also be used for pleasure, please provide percentage of personal use: Is this vehicle parked at garaging location above at night? Yes No If no, please provide address: Street Address Address Line 2 City Province Postal Code Radius of OperationNormal Operating Distance - One Way: kms % of Total Trips: % Maximum Operating Distance - One way: kms % of Total Trips: % No. of Trips per Month Beyond the Normal Distance from Place Usually Kept: Most Common Destinations - list cities and provinces: Other Uses Is this vehicle used to haul trailers: Yes No Merchandise Carried: Do you do any deliveries: Yes No Do you do any hauling for others: Yes No Is there any U.S.A Exposure: Yes No Is there any machine, equipment or decals mounted on or attached to the vehicle: Yes No If yes, please provide description and value: Do you do any snow removal: Yes No
Automobile 4VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Commercial Use Sales Calls If this vehicle will also be used for pleasure, please provide percentage of personal use: Is this vehicle parked at garaging location above at night? Yes No If no, please provide address: Street Address Address Line 2 City Province Postal Code Radius of OperationNormal Operating Distance - One Way: kms % of Total Trips: % Maximum Operating Distance - One way: kms % of Total Trips: % No. of Trips per Month Beyond the Normal Distance from Place Usually Kept: Most Common Destinations - list cities and provinces: Other Uses Is this vehicle used to haul trailers: Yes No Merchandise Carried: Do you do any deliveries: Yes No Do you do any hauling for others: Yes No Is there any U.S.A Exposure: Yes No Is there any machine, equipment or decals mounted on or attached to the vehicle: Yes No If yes, please provide description and value: Do you do any snow removal: Yes No
Automobile 5VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Commercial Use Sales Calls If this vehicle will also be used for pleasure, please provide percentage of personal use: Is this vehicle parked at garaging location above at night? Yes No If no, please provide address: Street Address Address Line 2 City Province Postal Code Radius of OperationNormal Operating Distance - One Way: kms % of Total Trips: % Maximum Operating Distance - One way: kms % of Total Trips: % No. of Trips per Month Beyond the Normal Distance from Place Usually Kept: Most Common Destinations - list cities and provinces: Other Uses Is this vehicle used to haul trailers: Yes No Merchandise Carried: Do you do any deliveries: Yes No Do you do any hauling for others: Yes No Is there any U.S.A Exposure: Yes No Is there any machine, equipment or decals mounted on or attached to the vehicle: Yes No If yes, please provide description and value: Do you do any snow removal: Yes No
Automobile 6VIN/ Serial Number: Year: Make: Model: Primary Driver: First Name Last Name Vehicle Use: Commercial Use Sales Calls If this vehicle will also be used for pleasure, please provide percentage of personal use: Is this vehicle parked at garaging location above at night? Yes No If no, please provide address: Street Address Address Line 2 City Province Postal Code Radius of OperationNormal Operating Distance - One Way: kms % of Total Trips: % Maximum Operating Distance - One way: kms % of Total Trips: % No. of Trips per Month Beyond the Normal Distance from Place Usually Kept: Most Common Destinations - list cities and provinces: Other Uses Is this vehicle used to haul trailers: Yes No Merchandise Carried: Do you do any deliveries: Yes No Do you do any hauling for others: Yes No Is there any U.S.A Exposure: Yes No Is there any machine, equipment or decals mounted on or attached to the vehicle: Yes No If yes, please provide description and value: Do you do any snow removal: 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: