Insurance Quote - Residential

Personal Information

First Name:

Last Name:

Email Address:

Address:

City:

Province:

Postal Code:

Home Phone:

Business Phone:

Fax Number:

Occupation:

Vehicle Information

Registered Owner:

First Name

Last Name

Vehicle

Make:	Model :
Year:	Type
	4X4	Yes	No
Usage:
Annual Kilometres (Approx)
Daily Kilometres. ( Approx )
Anti Theft Device	Number of months spent out of the country in your vehicle

Main use for your vehicle:	Pleasure	Business	Commute
If you selected Business please describe the type of business and the cargo carried.

Current Policy Information

Insurance Company

Policy Number

Policy expiry Date

Driver Information

Note:Driver's Licence numbers may be significant to the uderwriting accuracy and will speed the return of your quotation request.

First Name:

Last Name:

Driver's Lic. Number

Relation to applicant

Date of birth

Sex:

Married?
Driver's training?
Do you hold a valid licence in another country

Please indicate the number of years each driver has been licenced :	Driver 1
	Driver 2

Indicate if the driver has had insurance cancelled for any of the following reasons :
Nonpayment		Fraud		Misrepresentation

Claims Information

Please check off all that apply.	Yes
Claims or accidents in the last 6yrs.
Convictions, fines or traffic violations in the last 3yrs.
Losses due to theft, vandalism or other comprehensive claims in the last 6yrs.
Any licence suspensions in the last 6 yrs.

If none of the above boxes are checked please skip the following section by clicking here.

List the two most recent claims or accidents in the past 6 years

Claim 1

Date:	Was this driver at fault?
Did your insurance company pay out the claim?
How much was paid out on the claim ?( if known)
Own car		$
Other car		$
Please list the details of the accident:

Claim 2

Date:	Was this driver at fault?
Did your insurance company pay out the claim?
How much was paid out on the claim ?( if known)
Own car		$
Other car		$
Please list the details of the accident:

Are there more than two claims?

If you answered yes to the above question please list the details of all claims in the last six years below.

List losses due to theft, vandalism or other comprehensive claims in the past 6 years.

List convictions, fines or traffic violations within the past 3 years

State the details if drivers licence has been suspended or revoked in the past 6 years

Coverage Required


Mandatory Coverage Liability - Please select the amount.
Vehicle 1		Vehicle 2
Statutory Coverage: Accident Benefits Family Protection Endorsement
Loss or Damage Deductible - Please select the amount.
Collision or Upset:
Do you require coverage for Loss of Use?
Please recheck to make sure you have supplied all information requested. Please make sure each section in filled, so that all your applicable discounts can be determined.

By submitting this form you agree that the information you provided above is true and accurate.

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Important:Please be accurate in completing this form. Your quotation will be based on the information you give us today. If these facts change, your rate will be subject to adjustment.
The Information transmitted is used by this brokerage to develop a prospect profile, and may or may not be used in the pricing of any estimated policy premiums.