* - Optional Fields
Information obtained from this form will be kept confidential and will only be used to help establish a quote
Name:
E-mail:
Phone #:
Address:
*
City:
Postal Code:
Province:
Date of Birth:
(DD/MM/YY)
/ / 19
Gender:
Male
Female
Marital Status:
Married
Single
Driver Training:
Yes
No
No. of Years
Year of
Automobile
Make of
automobile
Model:
# of years driving in
Canada:
Type of License
G
Level
G2
Level
How many at
fault accidents/claims in
How many no
fault accidents/claims in
Date of last accident/claim (if any)
How many convictions/tickets in the past 3
years?
If yes, what kind of tickets/convictions?
Liability Limit:
1,000,000
2,000,000
Collision
Deductible:
Comprehensive
Deductible:
Use of
automobile
Business
Pleasure
Commercial
Annual km used:
Distance driven to work one way
0
- 5km
5 -
16km
16+
km
What is your contact
preference?
Phone
E-mail
Insured Consecutively
4
Doors
2
Doors
Convertible
the last 6 years?
the last 6 years?