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Group Auto Insurance Quote

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

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Full Name*
Postal Code*
Date of Birth*
Marital Status*
Gender*
Driver's Licence Number*
COVERAGES REQUESTED
COVERAGES REQUESTED
- Liability
- Collision
- Comprehensive
- Loss of Use
- Accident Waiver
WHAT HAS BROUGHT YOU TO US TODAY?**
OFFICE LOCATION AND/OR BROKER NAME
Referred by:
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:
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
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?
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
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)
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

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