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Auto Insurance
Name:
Address:
City:
Province:
Postal Code:
Phone number:
Email:
Driver's License #:
Year G1 Attained:
Year G2 Attained:
Year G Attained:
Number of driving convictions in past three years:
Year, make, and model of vehicle:
Do you use your vehicle for business:
Yes
No
Do you use your vehicle to commute to and from work:
Yes
No
If so, number of km one way to work:
# of years you have consistently had an auto policy in force or been listed as a driver on someone else’s policy:
Number of at fault claims in the past 10 years:
If any, the approximate date of the last claim:
Policy cancelled for non-payment in the past 3 years?:
Yes
No
Was your policy lapsed for any other reason by the insurance company:
Liability limit requested:
$2,000,000
$1,000,000
Coverage Preferred:
All perils
Collision
Comprehensive
Specified perils
Deductible:
$500
$250
$1,000
Current insurance company and renewal date:
Which insurance company has your current property insurance:
Marital status of principal driver:
Married
Single
Additional vehicles to be quoted:
Yes
No
Are there other household drivers?:
Yes
No
Driver 1:
Spouse / Partner
Child / Dependant
Other (please specify)
Driver 2:
Spouse / Partner
Child / Dependant
Other (please specify)
Driver 3:
Spouse / Partner
Child / Dependant
Other (please specify)
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