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Auto Insurance

General Information
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Underwriting Information
Have you ever had insurance cancelled for non payment?	Yes    No
How many years have you been continuously insured?
Have you been previously insured?	Yes    No
Name of previous insurance company:
Expiry of previous insurance:
Do you own your own home?	Yes    No
What is the expiry date of that policy?
Driver(s) Information	#1	#2	#3
Name of Driver:
Date of Birth:
Drivers Licence#:
Years licensed in Canada:
License class:	G G1 G2	G G1 G2	G G1 G2
Date Licenced (G):
Date Licenced (G2):
Date Licenced (G1):
Sex:	Male Female	Male Female	Male Female
Young Drivers Training:	Yes No	Yes No	Yes No
Convictions in past 6 years (including suspensions):	0 1 2 3 More than 3	0 1 2 3 More than 3	0 1 2 3 More than 3
ALL accidents (including not at fault) and/or Claims in past 10 years:	0 1 2 3 More than 3	0 1 2 3 More than 3	0 1 2 3 More than 3
Claims Information
#1:	Type of Claim: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft Date: (mm/yyyy) Driver Involved:  N/A Driver #1 Driver #2 Driver #3
#2:	Type of Claim: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft Date: (mm/yyyy) Driver Involved:  N/A Driver #1 Driver #2 Driver #3
#3:	Type of Claim: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft Date: (mm/yyyy) Driver Involved:  N/A Driver #1 Driver #2 Driver #3
Vehicle Information	Vehicle #1	Vehicle #2	Vehicle #3
Vehicle make:
Year:
Model:
Serial Number:
Purchase Price:
New/Used:
Date Purchased:
Vehicle Use	Vehicle #1	Vehicle #2	Vehicle #3
Who is primary driver:	N/A Driver #1 Driver #2 Driver #3	N/A Driver #1 Driver #2 Driver #3	N/A Driver #1 Driver #2 Driver #3
Use:	Commute Pleasure Only Business Commercial	Commute Pleasure Only Business Commercial	Commute Pleasure Only Business Commercial
KM driven one way to work:
Kilometres driven per year:	0-5000 5001-10000 10001-15000 15001-20000 20001-25000 over 25000	0-5000 5001-10000 10001-15000 15001-20000 20001-25000 over 25000	0-5000 5001-10000 10001-15000 15001-20000 20001-25000 over 25000
Modified?	Yes	Yes	Yes
Tow Trailers?	Yes	Yes	Yes
Carry Pass for compensation?	Yes	Yes	Yes
Coverage Required	Vehicle #1	Vehicle #2	Vehicle #3
Liability Limit:	$1,000,000 $2,000,000 $5,000,000	$1,000,000 $2,000,000 $5,000,000	$1,000,000 $2,000,000 $5,000,000
All Perils deductible:	None $250 $500 $1,000	$250 $500 $1,000	$250 $500 $1,000
Collision deductible:	None $250 $500 $1,000	$250 $500 $1,000	$250 $500 $1,000
Specified Perils deductible:	None $250 $500 $1,000	$250 $500 $1,000	$250 $500 $1,000
Comprehensive deductible:	None $250 $500 $1,000	$250 $500 $1,000	$250 $500 $1,000
Unrepaired Damage?	Yes	Yes	Yes
Lien holder/Lessor?	Yes	Yes	Yes
Discounts
MVD	Yes	Yes	Yes
MPD	Yes	Yes	Yes
UNIV	Yes	Yes	Yes
RETIREE	Yes	Yes	Yes
Comments:
	Disclaimer