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Auto Insurance Request Quote Form
Driver's Information
First name: *
Last name: *
Middle name: *
Address: *
City: *
Postal code: *
Home phone:
 
Fax number:
 
Cell phone:
 
Email"
Marital Status: *
Occupations: *
Age: *
Licencing information
Date licensed:
IF Licenced Prior to April 1994
When did you obtain first your G licence? *
IF licenced after April 1994
When did you first obtain your G1 Licence? Month and Year:
When did you obtain first your G2 Licence? Month and Year:
When did you first obtain your G Licence? Month and Year:
Did you obtain your Driving School Certificate? *
Suspensions
Has your drivers licence been suspended in the past 6 years?
Answer: *
What was the effective date of your first suspension?
Month and year:
What was the reinstatement date?
Month and Year:
Choose the reason for first suspension:
What was the effective date of your second suspension?
Month and Year:
What was the reinstatement date?
Month and Year:
Coose the Reason for Second Suspension:
Driving History
Accidents or Claims Information For Past 6 Years
How many accident benefits were paid in 6 years
Date: Day / Month / Year
Types of Claims/Accidents
Tickets and Convictions
Tickets (Conviction) Infos For Past 3 Years (No parking)
Number of tickets: *
Type 1 - Minor Ticket 1
Type 1 - Minor Ticket 2
Type 1 - Minor Ticket 3
Type 1 - Minor Ticket 4
Type 1 - Minor Ticket 5
Type 1 - Minor Ticket 6
Number of Major Tickets:
Type 2 Major Ticket 1
Type 2 Major Ticket 2
Type 2 Major Ticket 3
Number 3 tickets:
TYPE 3 SERIOUS OR CRIMINAL CODE
TYPE 3 SWRIOUS OR CRIMINAL CODE
TYPE 3 SERIOUS OR CRIMINAL CODE
Have you had your prior insurance? *
If YES, for how long? *
Has an insurance company cancelled your policy in the past 3 years ?r
Answer: *
If YES, what was the reason for cancellation?
If policy was cancelled for non-payment:
Was your last policy cancelled for non-payment?
Have you had two or more non-payment cancellation in 3 years?
Do you have auto insurance currently?
If no current insurance:
Date of last insurance, month and year:
Vehicle information
Model year of vehicle: *
Vehicle make: *
Doors: *
Wheel drive *
Cylinders *
Registered owner *
Is the vehicle:
Usage *
KM driven one way to work
Km driven per year
Occasional driver
Age:
Date licensed:
When did occasional driver obtained G1 Licence?
Date: Month and year
When did occasional driver obtained G2 Licence?
Date: Month and year
When did occasional driver obtained G Licence?
Conviction in three years
How many:
Coverages required
Coverages required: *
Liability: *
Collision: Comprehensive: *
Effective date
Estimated effective date of policy: *
Write your message: