Name: 
     Address: 
        City:  Province: 
 Postal Code:  Phone:  FAX: 

 E-Mail Address: 
  How Should We Contact You With A Quote? 
E-Mail
Regular Mail
FAX
Phone

Please indicate your vehicle's

          YEAR     MAKE    MODEL    # of Doors/Hatchback  USE

Auto #1:   
To & From Work
Pleasure
Business
Recreational
commercial
Farm

Kilometers driven one way to work:  annually:


Auto #2:   
To & From Work
Pleasure
Business
Recreational
commercial
Farm

Kilometers driven one way to work:  annually:


If you have more vehicles, please add in the remarks section (below).

                    AUTO #1       AUTO #2

Liability Limit:

Collision Deductibles:

Comprehensive Deductibles:

Specified Perils Deductibles:

All Perils Deductibles:

Would you like Loss of Use coverage?

Would you like to make monthly payments?

Who were you most recently insured with? What was your policy number? When does/did it expire?

Driver #1
Name 
 Age  Sex 
Male
Female
 Marital Status 
Single
commeronlaw
Married
Divorced
Widowed

Date Licensed (MM/YY)  Class  Driver Training 
No
Yes

Percentage Use of Each Vehicle:   Auto #1    Auto #2 

Driver #2
Name 
 Age  Sex 
Male
Female
 Marital Status 
Single
commeronlaw
Married
Divorced
Widowed

Date Licensed (MM/YY)  Class  Driver Training 
No
Yes

Percentage Use of Each Vehicle:   Auto #1    Auto #2 

Driver #3
Name 
 Age  Sex 
Male
Female
 Marital Status 
Single
commeronlaw
Married
Divorced
Widowed

Date Licensed (MM/YY)  Class  Driver Training 
No
Yes

Percentage Use of Each Vehicle:   Auto #1    Auto #2 

If you have more drivers, please add in the remarks section (below).


To the best of you're knowledge:

1) Has any license, permit, etc. of any driver in the household or
business, been suspended or cancelled in the last 6 years? 
No
Yes

If YES, please give details:

2) Has any insurance company cancelled automobile insurance for
any driver  in the last 3 years? 
No
Yes

If YES, please give details:

3) Has any auto insurance policy issued to you or any driver been denied
or cancelled due to material misreprentation in the last 3 years? 
No
Yes
If YES, please give details:

4) Have you, or any driver been found by a court to have commeritted a fraud
in connection with auto insurance? 
No
Yes

If YES, please give details:

For any claims up to 6 years ago, or convictions up to 3
years ago, please provide the following information:

      · Date of incident;          · Driver's name;
      · Which vehicle;             · Type of claim or convition;
      · Details;                   · Amount Paid;

Please use the following space to enter information regarding additional
vehicles, drivers, or any other information you feel may be needed.




When would you like this quote by (number of days)?  

            


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