Auto Insurance Quote Request

*Name:
*Phone:
*Email:
Address:
City:
Province:
Postal Code:
Have you ever had insurance cancelled or refused?	Yes     No
Do you currently insure your car?	Yes     No
If not, have you had insurance for 12 consecutive months within the last 6 years?	Yes     No
Coverage Renewal Date? (dd/mm/yyyy)
Driver(s) Information:	#1 #2 #3
Name of Driver:
Drivers License #:
Years licensed in Canada:
License class:	G G1 G2 G G1 G2 G G1 G2
Sex:	Male Female Male Female Male Female
Marital status:	Married Single Common-law Married Single Common-law Married Single Common-law
Driving school:	Yes No Yes No Yes No
Retired?	Yes No Yes No Yes No
Minor traffic convictions in the last 3 yrs:	0 1 2 3 More than 3 0 1 2 3 More than 3 0 1 2 3 More than 3
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):	0 1 2 3 More than 3 0 1 2 3 More than 3 0 1 2 3 More than 3
Are you currently insured?	Yes     No
Name of previous insurance company:
Previous Policy #:
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 10 years?	Yes     No
Claims Information:	Claims Date (mm/yyyy) Driver involved
#1:	N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3
#2:	N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3
#3:	N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3
Vehicle Information:	Vehicle #1 Vehicle #2
VIN #:
Vehicle make:
Year:
Model:
Style:	2-door 2-door hatch 4-door 4-door hatch Wagon SUV Pick up Van 2-door 2-door hatch 4-door 4-door hatch Wagon SUV Pick up Van
Use:	Commute Pleasure Only Business Commercial Commute Pleasure Only Business Commercial
KM driven one way to work:
Kilometers driven per year:	0-5,000 5,001-10,000 10,001-15,000 15,001-20,000 20,001-25,000 over 25,000 0-5,000 5,001-10,000 10,001-15,000 15,001-20,000 20,001-25,000 over 25,000
Who is primary driver:	N/A Driver #1 Driver #2 Driver #3 N/A Driver #1 Driver #2 Driver #3
Coverage Required:	Vehicle #1 Vehicle #2
Liability:	$200,000 $500,000 $1,000,000 $2,000,000 $200,000 $500,000 $1,000,000 $2,000,000
Collision deductible:	$1,000 $500 $300 $300 $500 $1,000
Comprehensive deductible:	$100 $300 $500 $1,000 $100 $300 $500 $1,000
All Perils deductible:	$100 $300 $500 $1,000 $100 $300 $500 $1,000
Disclosure and Privacy Statement