Auto Insurance Form
Please complete this application for an insurance quote.
Personal Info
Name Insured
*
Policy Address
Street Address
City
Province
Postal Code
Number of Drivers
*
Please Select
1
2
3
4
5
More
Driver 1
*
Name
License Number
Driver 2
*
Name
License Number
Driver 3
*
Name
License Number
Driver 4
*
Name
License Number
Driver 5
*
Name
License Number
Please list all additional names and license numbers
*
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Next
Vehicle Info
Please send a copy of the ownership or bill of sale.
Number of Vehicles
*
Please Select
1
2
3
4
5
More
Vehicle 1 - VIN #
If unable to get VIN, please state year, make & model.
Vehicle 1 - Primary Driver
Vehicle 1 - Purchase Method
*
Outright
Financed
Leased
Vehicle 1 - Purchase Date
Vehicle 1 - Annual Usage (kms)
*
Vehicle 1 - Daily one-way commute distance (work,school etc)
If no commute, please leave blank.
Vehicle 1 - Parking
Please Select
Driveway
Garage
Street
Parking Lot
Underground Parking Garage
Other
Vehicle 1 - Do you have winter tires?
Yes
No
Vehicle 2 - VIN #
If unable to get VIN, please state year, make & model.
Vehicle 2 - Primary Driver
Vehicle 2 - Purchase Method
*
Outright
Financed
Leased
Vehicle 2 - Purchase Date
Vehicle 2 - Annual Usage (kms)
*
Vehicle 2 - Daily one-way commute distance (work,school etc)
If no commute, please leave blank.
Vehicle 2 - Parking
Please Select
Driveway
Garage
Street
Parking Lot
Underground Parking Garage
Other
Vehicle 2 - Do you have winter tires?
Yes
No
Vehicle 3 - VIN #
If unable to get VIN, please state year, make & model.
Vehicle 3 - Primary Driver
Vehicle 3 - Purchase Method
*
Outright
Financed
Leased
Vehicle 3 - Purchase Date
Vehicle 3 - Annual Usage (kms)
*
Vehicle 3 - Daily one-way commute distance (work,school etc)
If no commute, please leave blank.
Vehicle 3 - Parking
Please Select
Driveway
Garage
Street
Parking Lot
Underground Parking Garage
Other
Vehicle 3 - Do you have winter tires?
Yes
No
Vehicle 4 - VIN #
If unable to get VIN, please state year, make & model.
Vehicle 4 - Primary Driver
Vehicle 4 - Purchase Method
*
Outright
Financed
Leased
Vehicle 4 - Purchase Date
Vehicle 4 - Annual Usage (kms)
*
Vehicle 4 - Daily one-way commute distance (work,school etc)
If no commute, please leave blank.
Vehicle 4 - Parking
Please Select
Driveway
Garage
Street
Parking Lot
Underground Parking Garage
Other
Vehicle 4 - Do you have winter tires?
Yes
No
Vehicle 5 - VIN #
If unable to get VIN, please state year, make & model.
Vehicle 5 - Primary Driver
Vehicle 5 - Purchase Method
*
Outright
Financed
Leased
Vehicle 5 - Purchase Date
Vehicle 5 - Annual Usage (kms)
*
Vehicle 5 - Daily one-way commute distance (work,school etc)
If no commute, please leave blank.
Vehicle 5 - Parking
Please Select
Driveway
Garage
Street
Parking Lot
Underground Parking Garage
Other
Vehicle 5 - Do you have winter tires?
Yes
No
Please list all info regarding any additional vehicle(s).
Back
Next
Insurance Info
Does any driver have any claims/accidents in past 6 years?
Yes
No
Please provide details for each incident
Does any driver have any tickets, driving convictions or suspensions in last 3 years?
Yes
No
Please provide details for each infraction
Has any driver had their license lapse to where they had to redo G1, G2 or G test?
Yes
No
Please provide name(s) and most recent licensing dates
Submit
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