First Name:*
Last Name:*
Address:*
City:*
Province (Ontario Residents Only):
Postal Code:*
Home Phone:*
Work Phone:*
Ext.:
Email:*
If yes, please write the date it is set to expire:
Number of years of consecutive insurance:*
Name:
Age:
Years Licensed:
Licence Class:
Sex: Select option Male Female
Marital Status: Select option Married Single
Minor Traffic Conviction: Select option None One Two Three Four Five or More
Major Traffic Conviction: Select option None One Two Three or More
Type of Claim: Select option At-Fault Not At-Fault Theft Vandalism Windshield
Date of Claim:
Driver Involved: Select option Driver #1 Driver #2 Driver #3
Type of Claim: Select option At-Fault Not At-Fault Theft Vandalism Windshield
Date of Claim:
Driver Involved: Select option Driver #1 Driver #2 Driver #3
Type of Claim: Select option At-Fault Not At-Fault Theft Vandalism Windshield
Date of Claim:
Driver Involved: Select option Driver #1 Driver #2 Driver #3
Year:
Make:
Model:
Style: Select option Two Door Two Door Hatch Four Door Four Door Hatch Station Wagon Sports Utility Pick-Up Truck Van
Annual Kilometres:
Primary Driver: Select option Driver #1 Driver #2 Driver #3
Use: Select option Pleasure Only Commute > 5km Commute 5 - 24km Commute Over 25km Business Use
Liability Limit: Select option $1,000,000 $2,000,000
Collision Deductible: Select option No Deductible $300 $500 $1,000
Comprehensive Deductible: Select option No Deductible $300 $500 $1,000
Year:
Make:
Model:
Style: Select option Two Door Two Door Hatch Four Door Four Door Hatch Station Wagon Sports Utility Pick-Up Truck Van
Annual Kilometres:
Primary Driver: Select option Driver #1 Driver #2 Driver #3
Use: Select option Pleasure Only Commute > 5km Commute 5 - 24km Commute Over 25km Business Use
Liability Limit: Select option $1,000,000 $2,000,000
Collision Deductible: Select option No Deductible $300 $500 $1,000
Comprehensive Deductible: Select option No Deductible $300 $500 $1,000
Comments:
