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?

Are you currently a homeowner?

Expiry date with present Insurer
(dd/mm/yyyy)

Driver(s) Information:

#1

#2

#3

Name:

Age:

Years licensed in Canada:

License class:

Sex:

Marital status:

Driving school:

Retired?

Minor traffic convictions in the last 3 yrs:

Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):

Have any of above drivers had their licenses suspended or revoked in the past 3 years?

Have any of the drivers above had accidents or insurance claims in the past 10 years?

Claims Information:

#1:

#2:

#3:

Vehicle Information:

Vehicle make:

Year:

Model:

Style:

Use:

Kilometres driven per year:

Who is primary driver:

Coverage Required:

Liability:

Collision deductible:

Comprehensive deductible: