Belliveau Insurance - Auto Insurance Quote Request

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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?	Yes No
Do you currently insure your car?	Yes No
If not, have you had insurance for 12 consecutive months within the last 6 years?	Yes No
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?	Yes No
Have any of the drivers above had accidents or claims in the past 10 years?	Yes No
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: