The information we gather is only to be able to better assist us to calculate a quote for you. A representative will contact you within 24 hours and further assist you with your quote.


  
* Name: Address  
* Phone Number City/Town:  
* Email: * Postal Code  
*Required  
 

 
Have you ever had insurance cancelled or refused? Yes   No
Do you currently insure your vehicle? Yes   No  
If not, have you had insurance for 24 consecutive months within the last 6 years? Yes   No  
How many years of continuous insurance have you had in North America?    
 
Drivers Information #1 #2 #3  
Name:  
D.O.B.: (dd/mm/yyyy)  
Drivers License #:  
Years licensed in Canada:  
License class:  
Sex:  
Driving School: Yes   No Yes   No Yes   No  
Retired: Yes   No Yes   No Yes   No  
Minor traffic convictions
in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
Expiry date of current policy? (dd/mm/yyyy)    
How Many years of continuous insurance?    
Have any of above drivers had their licenses suspended or lapsed in the past 6 years? Yes   No  
Have any of the drivers above had accidents or claims in the past 6 years? Yes   No  
       
Claims Information: Claims Date (mm/yyyy) Driver involved
#1  
#2  
#3  
 
Vehicle Information: Vehicle #1 Vehicle #2 Vehicle #3
Vehicle make:  
Year:
Model:
Style:
Use:
KM driven one way to work:
Kilometers driven per year:
Who is primary driver:
       
Coverage Required: Vehicle #1 Vehicle #2 Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:
       
 

 

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