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| Name: |
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| Address: |
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| City: |
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| Province: |
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| Postal Code: |
(X1Y 2Z3) |
| Phone Number: |
(123-456-7890) |
| Email Address: |
(xxx@yyyy.zzz) |
| Have you ever had insurance cancelled or refused? |
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Do you currently insure
your car? |
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| If not, have you had insurance for 12 consecutive months within the last 6 years? |
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| When should coverage start? |
(dd/mm/yyyy) |
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| Driver(s) Information
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#1 |
#2 |
#3 |
| Name of Driver: |
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| Date of Birth: |
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| Drivers Licence#: |
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| Years licensed in Canada: |
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| License class: |
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| Sex: |
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| Marital status: |
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| Driving school: |
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| Retired? |
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Minor traffic convictions
in the last 3 yrs: |
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| Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.): |
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| Are you currently insured? |
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| Name of previous insurance company: |
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| Have any of above drivers had their licenses suspended or lapsed in the past 6 years? |
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| Have any of the drivers above had accidents or claims in the past 10 years? |
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| Claims Information
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| #1: |
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| #2: |
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| #3: |
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| Vehicle Information |
Vehicle #1 |
Vehicle #2 |
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| Vehicle make: |
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| Year: |
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| Model: |
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| Style: |
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| Use: |
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| KM driven one way to work: |
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| Kilometres driven per year: |
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| Who is primary driver: |
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| Coverage Required |
Vehicle #1 |
Vehicle #2 |
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| Liability: |
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| Collision deductible: |
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| Comprehensive deductible: |
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Disclaimer |
