_ Personal Information

First Name:

Last Name:

E-mail Address:

Address:

Apt. Number:

City:

Province: Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal Code:

Home Phone:

Business Phone:

Fax Number:

Occupation:

__ Vehicle Information

Registered Owner's First Name:

Registered Owner's Last Name:

Vehicle Make:

Model: ____Year:

Type: 2 Door 4 Door Van Wagon Truck ____4X4: Yes No

Annual Kilometres (approx):

Daily Kilometres (approx):

Anti Theft Device: Yes No

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 typeof business and cargo carried:

__ Current Policy Information

Insurance Company:

Policy Number:

Policy Expiry Date:

__ Driver Information

NOTE: Drivers Licence numbers may be significant to the underwriting accuracy and will speed the return of your quotation request.

First Name:

Last Name:

Drivers Licence Number:

Relation to Applicant:

Date of Birth:

Married? Yes No

Driver's Training? Yes No

Do you hold a valid licence in another country? Yes No

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

Please 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:

Claims or accidents in the last 6 years

Convictions, fines, or traffic violations in the last 3 years

Losses due to theft, vandalism or other comprehensive claims in the last 6 years

Any licence suspensions in the last 6 years

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 drver at fault? Yes No

Did your insurance company pay out the claim? Yes No

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 drver at fault? Yes No

Did your insurance company pay out the claim? Yes No

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 2 claims? Yes No

If you answered "Yes" to the above question, please list below the details of all the claims in the last 6 years:

List the losses due to theft, vandalism or other comprehensive claims in the last 6 years:

List convictions, fines or traffic violations in the last 3 years:

State the details if your drivers licence has been suspended or revoked in the last 6 years:

__Coverage Required

Mandatory Coverage Liability (please select the amount):

Vehicle 1: $500,000 $1,000,000 $2,000,000

Vehicle 2: $500,000 $1,000,000 $2,000,000

Statutory Coverage (please select the amount):

Accident Benefits, Family Protection Endorsement, Loss or Damage Deductable: $100 $250 $500

Collision or Upset: $500 $1,000

Do you require coverage for Loss of Use? Yes No

Please recheck to make sure you have supplied all information requested.
Please make sure each section is filled, so that all your applicable discounts can be determined.

By submitting this form you agree that the information you are providing is true and accurate

Coverages cannot be bound or changes made through our website or e-mail. You must call our office and speak to a Licenced Insurance Broker.