Automobile Insurance
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Have you ever had insurance cancelled or refused?
Yes     No
Do you currently have insurance?
Yes     No
How many years have you had a continuous insurance policy?
When should coverage start?
Driver(s) Information:
#1 #2 #3
Name:
Date of Birth :
Years licensed in Canada:
Earliest Date License :
 
G
 
G2
     
Sex:
Marital status:
Driving school:
Minor traffic convictions in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, speeding 50km over, etc.):
Have any drivers had their licenses suspended in the past 3 years?
Yes     No
Have any of the drivers had accidents in the past 6 years?
Yes     No
Claims Information:
Claims Date (mm/yyyy) Driver involved
#1:
#2:
#3:
   
Vehicle Information:
Vehicle #1 Vehicle #2
Year:
Vehicle make:
Model:
# of Km to work :
Who is primary driver:
   
Coverage Required:
Vehicle #1 Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:
Comments:
 

Disclaimer
This is a request to provide a quote only and is not an insurance policy. It is not an offer of insurance. Further information may be required in order for a complete quote to be provided. This quote request contains some information about coverage offered but it does not list all of the conditions and exclusions that apply to the described coverage. The actual wording of the policy governs all situations.

This quote request is only available to persons resident in the Province of Ontario.

The products described are subject to change without notice at any time.