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Auto Insurance Quote Request


Auto Insurance

Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Have you ever had insurance cancelled or refused?    
Do you currently insure your car?    
If not, have you had insurance for 12 consecutive months within the last 6 years?    
When should coverage start?
Driver(s) Information: #1 #2 #3
Name of Driver:
Date of Birth:
Drivers License #:
Years licensed in Canada:
License Class:
Sex:
Marital Status:
Driving School:
Retired?
Minor traffic convictions in the last 3 years:
Major traffic convictions in the last 3 years (careless or impaired driving, refusing breathalyzer, etc.):
Name of previous insurance company:
Have any of the above drivers had their licenses suspended or lapsed in the past 10 years?    
Have any of the drivers above had accidents or claims in the past 10 years?    
Claims Information: Claims Date (mm/yyyy) Driver Involved
#1:
#2:
#3:
 
Vehicle Information: Vehicle #1 Vehicle #2
Vehicle Make:
Vehicle Year:
Vehicle Model:
Style:
Use:
KM driven one way to work:
KM driven per year:
Who is the primary driver:
 
Coverage Required: Vehicle #1 Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible: