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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
Driver's Licence Number*

COVERAGES REQUESTED
COVERAGES REQUESTED
- Liability
- Collision
- Comprehensive
- Loss of Use
- Accident Waiver
What has brought you to us today?*
Referred By (Full Name):
Office location and/or your broker's name:
Group Type:
If other, how?*
PREFERRED METHOD OF CONTACT*
Phone*
Email Address*

Vehicle Details
Vehicle Year
Vehicle Make
Vehicle Model
VIN Number (if possible)
PURCHASE DATE
MM slash DD slash YYYY
PRIMARY USE*
Total Kilometres Driven Annually
Total Kilometres Driven to Work (One way)
Do you have winter tires?
Second Vehicle
Vehicle Year
Vehicle Make
Vehicle Model
VIN Number (if possible)
PURCHASE DATE
MM slash DD slash YYYY
PRIMARY USE*
Total Kilometres Driven Annually
Total Kilometres Driven to Work (One way)
Do you have winter tires?

Your History
Date of Completion of G1*
Date of Completion of G2*
Date of Completion of G
Have you completed Driver Training?
Have you been issued any tickets in the past 3 years?
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?
Were you at fault or 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?
Reason for licence suspension
Date of Licence Suspension
Length of Licence Suspension
Have you ever been cancelled for insurance non-payment?
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 Full Name*
Relationship to Driver*
If other, what is your relationship to the second driver?
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 been issued any tickets in the past 3 years?
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?
Were you at fault or 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?
Reason for licence suspension
Date of Licence Suspension
Length of Licence Suspension
Have you ever been cancelled for insurance non-payment?
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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