Auto Insurance

Name:

911 Address:

Phone:

Email:

Provide year, make, model:

Provide use of vehicle:

How many kilometers are driven to work or school one way (each day):

What is the annual kilometers:

Who is principal operator of vehicle:

Is the principal operator:

Date of birth of principal operator:

Date first licenced (G licence) for principal operator:

Do you wish common coverages? Common coverage is $1,000,000 liability, basic Accident Benefits, collision with $500 deductible, comprehensive with $300 deductible, opcf44 – family protection, opcf20 – loss of use:

Vehicle 2:

Provide year, make, model:

Provide use of vehicle:

How many kilometers are driven to work or school one way (each day):

What is the annual kilometers:

Who is principal operator of vehicle:

Is the principal operator:

Date of birth of principal operator:

Date first licenced (G licence) for principal operator:

Do you wish common coverages? Common coverage is $1,000,000 liability, basic Accident Benefits, collision with $500 deductible, comprehensive with $300 deductible, opcf44 – family protection, opcf20 – loss of use:

If you have over 2 vehicles, we will require the same information as noted above for each additional vehicle.

Are there any drivers in the household under 25 years of age?

Have you or any driver listed on this quote had any convictions in the last 3 years?

Have you even been convicted of fraud of auto insurance?

Have you or any driver listed on this quote had any claims in the past 6 years?

Has your auto policy ever been cancelled by another insurer?

Are you currently insured?

How do you want to be contacted? Please provide email address or phone number noting best time to call: