New Driver Addition Form

562272 ST NW EDMONTON AB T6B3J4 PH780-423-0909 FAX 780-485-0906
Company Name *
Policy Number*
Company Phone Number on File*
Please enter a valid phone number.
Company Email*
example@example.com
Driver Full Name*

First NameLast Name
Date of birth *

MonthDayYear
Date
Driver License Number*
Date received Class 1 license in Canada.*
No. of Years class 1 driving experience in North America*
No. of Minor infractions in past 3 Years
No. of Major infractions in past 3 years
Has this driver ever been suspended*
If yes, please advise circumstances
Has this driver had any claims in the past 5 years?*
If yes, please advise details
Will this driver be restricted to a specific power unit
If yes, please specify unit and ACV:
Attach recent abstract *

Cancelof
Attach Driver License Copy *

Cancelof
Signature of the driver *

Clear
Dated*

MonthDayYear
Date
In the event of a claim coverage will be void unless the declarations made above can be proven
Nordic MVR Authorization Form
I,*
driver name
hereby give consent to The Nordic Insurance Company of Canada and A-Kan Insurance to obtain a copy of my Driving Abstract.
Driver’s License Number*
Date of Birth (MM/DD/YY)*

MonthDayYear
Date
Insured/Company Name *
Policy Number
Date received Class 1 license in Canada *

MonthDayYear
Date
Date Signed*

MonthDayYear
Date
Signature of the driver *

Clear
Should be Empty: