Registered Owner
Registered Owner's First & Last Name
First Name
Last Name
Registered Owner's Date of Birth
-
Month
-
Day
Year
mm-dd-yyyy
Registered Owner's Drivers License Number
Will the registered owner also be the Principle Driver?
Yes
No
Principal Driver's First & Last Name
First Name
Last Name
Principal Driver's Date of Birth
-
Month
-
Day
Year
mm-dd-yyyy
Principal Driver's License Number
Are there any additional drivers who will occasionally drive the vehicle?
Yes
No
Please enter the Date of Birth and Driver's License Number for each additional driver
Rows
Date of Birth
Driver's License Number
Additional Driver #1
Additional Driver #2
Additional Driver #3
Additional Driver #4
Additional Driver #5
What is the main use of the vehicle?
Pleasure use only
Pleasure use and vehicle driven to or from, or part way to or from, work or school, a distance in excess of 15 km
Pleasure use and vehicle driven to or from, or part way to or from, work or school, a one-way distance not exceeding 15 km
Pleasure use and vehicle driven to or from work or school, with public transportation used for the balance of the journey
Business use (including pleasure use)
Enter the postal code of the vehicle's primary parking location (where it sleeps at night)
Has the principle driver or additional driver(s) had any tickets, penalty points or claims in the last 6 years?
Yes
No
Are you transferring insurance from a different vehicle?
Yes
No
Don't know
Enter the Driver's License Plate Number being transferred
Do you anticipate driving less than 5000 km per year?
Yes
No
Enter the name of the dealership at which you purchased your vehicle
Send
Should be Empty: