First Name:
Last Name:
Address:
City:
Province: *Ontario Residents Only
Postal Code:
Home Phone:
Work Phone: Ext.:
E-mail:
Do you currently have a policy with Meadowvale Insurance Brokers? Yes No
Do you currently have automobile insurance? Yes No
If yes, expiry date of existing policy:
Number of years of consecutive insurance:
Have you ever had your automobile insurance cancelled or refused? Yes No
Do you currently have property insurance? Yes No
Driver #1
Driver #2
Name:
Age:
Years Licenced:
Licence Class:
Sex:
Male Female
Marital Status:
Married Single
Driver Training:
Yes No
Minor Traffic Conviction:
None One Two Three Four Five or More
Major Traffic Conviction:
None One Two Three or More
Licence Suspension:
Previous Claim:
Type of Claim:
Date of Claim:
Driver Involved:
None At-Fault Not At-Fault Theft Vandalism Windshield
Date:
None Driver #1 Driver #2 Driver #3
Vehicle #1
Vehicle #2
Year:
Make:
Model:
Style:
Two Door Two Door Hatch Four Door Four Door Hatch Station Wagon Sports Utility Pick-up Truck Van
Annual Kilometres:
Primary Driver:
Driver #1 Driver #2 Driver #3
Use:
Pleasure Only Commute > 5km Commute 5 - 24km Commute Over 25km Business Use
Liability Limit:
$1,000,000 $2,000,000
Collision Deductible:
No Deductible $300 $500 $1,000
Comprehensive Deductible:
Loss of Use Coverage:
Waiver of Depreciation:
Thank-you for taking the time to submit your quote request. A broker will be in touch with you.
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