|
Auto Insurance Quote Form |
| Are you currently insured?
If yes, please indicate your insurance company and policy number: |
No
Yes:
|
| Expiry date of your current auto policy: |
|
Please indicate the number of years
you have had continuous insurance. |
|
1
2
3
4
5
6 |
If you have had no continuous years
of insurance, please explain why. |
|
| Please indicate the year, make and model of your vehicle. |
Year: |
| Make: |
| Model: |
Please indicate the following
coverages you require. |
| Liability:
$1,000,000
$2,000,000 |
| Collision Deductible:
$500
$1,000 |
Comprehensive Deductible:
$250
$500
$1,000 |
If you have combined your collision
and comprehensive into one "All Perils" coverage please indicate
your deductible. |
| All Perils:
$500
$1,000 |
Please indicate the use of
the vehicle. |
| Number of Km per Year:
|
|
Driven to work less than 8km |
|
Driven to work less than 16km |
|
Driven to work more than 16km |
|
Business use |
|
Pleasure use |
Driver Information |
| Driver 1: |
| Name: |
|
| Principal or occasional operator: |
|
| Years licensed: |
|
| Driver Training Certificate: |
No
Yes |
Accident claims or convictions:
|
Driver 2: |
| Name: |
|
| Principal or occasional operator: |
|
Relationship to insured:
Ex:
spouse, son, daughter |
|
| Years licensed: |
|
| Driver Training Certificate: |
No
Yes |
Accident claims or convictions:
|
Driver 3: |
| Name: |
|
| Principal or occasional operator: |
|
Relationship to insured:
Ex:
spouse, son, daughter |
|
Years licensed: |
|
| Driver Training Certificate: |
No
Yes |
Accident claims or convictions:
|
Driver 4: |
| Name: |
|
| Principal or occasional operator: |
|
Relationship to insured:
Ex:
spouse, son, daughter |
|
| Years licensed: |
|
| Driver Training Certificate: |
No
Yes |
Accident claims or convictions:
|
Driver 5: |
| Name: |
|
| Principal or occasional operator: |
|
Relationship to insured:
Ex:
spouse, son, daughter |
|
| Years licensed: |
|
| Driver Training Certificate: |
No
Yes |
Accident claims or convictions:
|
|
|
