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Car Insurance Quote
Please have the following information at hand:
•Year, make, model of vehicle to be quoted
•Driving records, licence and claim information
Please have the following information at hand: Year, make, model of vehicle to be quoted Driving records, licence and claim information
Step
1
of
3
33%
Full Name
*
Street Address
City
*
Province
Postal Code
*
Date of Birth
*
Gender
GENDER
Male
Female
Driver's Licence Number
*
COVERAGES REQUESTED
COVERAGES REQUESTED
Liability
Collision
Comprehensive
Loss of Use
Accident Waiver
What has brought you to us today?
*
WHAT HAS BROUGHT YOU TO US TODAY?*
I am an existing client
Family or Friend
Referred by/ am a Medallion member
Online Advertising
I am a group member
Social Media
Google
Referred by / am a Magenta client
Spotify/ Radio
Other
Referred By (Full Name):
Office location and/or your broker's name:
Group Type:
PLEASE SELECT GROUP TYPE:
Lions Club Member
Police / Law Enforcement
Firefighter
Medical First Responder
Conservation Officer
Other First Responder
Kitchener Wilmot Hydro
Bluewater Power
Johnson Controls
Noranco
Holliswealth
Justice of the Peace
OACCPP
If other, how?
*
PREFERRED METHOD OF CONTACT
*
PREFERRED METHOD OF CONTACT*
Email
Phone
Phone
*
Email Address
*
Vehicle Details
Vehicle Year
Vehicle Make
Vehicle Model
VIN Number (if possible)
PURCHASE DATE
MM slash DD slash YYYY
PRIMARY USE
*
PRIMARY USE
Pleasure and errands only
Commuting (work or school)
Business Use
Commercial Use (trades/deliveries etc)
Total Kilometres Driven Annually
Total Kilometres Driven to Work (One way)
Do you have winter tires?
DO YOU HAVE WINTER TIRES?
Yes
No
Second Vehicle
DO YOU HAVE A SECOND VEHICLE?
Yes
No
Vehicle Year
Vehicle Make
Vehicle Model
VIN Number (if possible)
PURCHASE DATE
MM slash DD slash YYYY
PRIMARY USE
*
PRIMARY USE
Pleasure and errands only
Commuting (work or school)
Business Use
Commercial Use (trades/deliveries etc)
Total Kilometres Driven Annually
Total Kilometres Driven to Work (One way)
Do you have winter tires?
DO YOU HAVE WINTER TIRES?
Yes
No
Your History
Date of Completion of G1
*
Date of Completion of G2
*
Date of Completion of G
Have you completed Driver Training?
HAVE YOU COMPLETED DRIVER TRAINING?
Yes
No
Have you been issued any tickets in the past 3 years?
HAVE YOU BEEN ISSUED ANY TICKETS IN THE PAST 3 YEARS?
No
Yes
Year of Ticket (1):
TYPE OF TICKET (1)
Speeding
Distracted Driving
Impaired Driving
Careless Driving
Minor Traffic Violation
Failure to have Insurance Card
Year of Ticket (2):
TYPE OF TICKET (2)
Speeding
Distracted Driving
Impaired Driving
Careless Driving
Minor Traffic Violation
Failure to have Insurance Card
Year of Ticket (3):
TYPE OF TICKET (3)
Speeding
Distracted Driving
Impaired Driving
Careless Driving
Minor Traffic Violation
Failure to have Insurance Card
Have you had any accidents in the past 10 years?
ANY ACCIDENTS IN THE PAST 10 YEARS?
No
Yes
Were you at fault or not at fault?
WERE YOU AT FAULT OR NOT AT FAULT?
At fault
Not at fault
Date of accident
Please list any additional claims you have made in the past 10 years:
Has your licence ever been suspended?
HAS YOUR LICENCE EVER BEEN SUSPENDED?
No
Yes
Reason for licence suspension
REASON FOR LICENCE SUSPENSION
Medical Reason
Suspension due to a conviction
Suspension due to driving under the influence
Other
Date of Licence Suspension
Length of Licence Suspension
LENGTH OF LICENCE SUSPENSION
3 Days
30 Days
60 Days
1 Year
Have you ever been cancelled for insurance non-payment?
HAVE YOU EVER BEEN CANCELLED FOR INSURANCE NON-PAYMENT?
No
Yes
Date of Cancellation
For how long did your insurance lapse, if at all?
How many years have you been continuously insured with the same insurance company?
Start date of your next policy (MM/DD/YYYY)
Do you have a second driver?
SECOND DRIVER
Yes
No
Date of Birth
*
Date of Completion of G1
Date of Completion of G2
Date of Completion of G
Have you completed Driver Training?
HAVE YOU COMPLETED DRIVER TRAINING?
Yes
No
Have you been issued any tickets in the past 3 years?
HAVE YOU BEEN ISSUED ANY TICKETS IN THE PAST 3 YEARS?
No
Yes
Year of Ticket:
TYPE OF TICKET
Speeding
Distracted Driving
Impaired Driving
Careless Driving
Minor Traffic Violation
Failure to have Insurance Card
Have you had any accidents in the past 10 years?
ANY ACCIDENTS IN THE PAST 10 YEARS?
No
Yes
Were you at fault or not at fault?
WERE YOU AT FAULT OR NOT AT FAULT?
At fault
Not at fault
Date of accident
Please list any additional claims you have made in the past 10 years:
Has your licence ever been suspended?
HAS YOUR LICENCE EVER BEEN SUSPENDED?
No
Yes
Reason for licence suspension
REASON FOR LICENCE SUSPENSION
Medical Reason
Suspension due to a conviction
Suspension due to driving under the influence
Other
Date of Licence Suspension
Length of Licence Suspension
LENGTH OF LICENCE SUSPENSION
3 Days
30 Days
60 Days
1 Year
Have you ever been cancelled for insurance non-payment?
HAVE YOU EVER BEEN CANCELLED FOR INSURANCE NON-PAYMENT?
No
Yes
Date of Cancellation
For how long did your insurance lapse, if at all?
How many years have you been continuously insured with the same insurance company?
Start date of your next policy (MM/DD/YYYY)
*
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