The following forms have been designed to ensure
you receive the most accurate automobile insurance quote possible.
Please make sure you accurately complete all required fields on each
screen.
Move between fields with mouse or tab key.
When finished click the "Submit Information" button. We will contact
you within the next
48 hours.
PERSONAL INFORMATION
First Name Last Name
Home Address Apt. Suite
City/Town Province
Postal Code
Home Telephone Business
Telephone Fax Telephone
Email Address
VEHICLE INFORMATION
VEH. NO. 1
VEH. NO. 2
VEH. NO. 3
Registered Owner
Year
Make (Ford, etc.)
Model (Escort GT, etc.)
2WD or 4WD
2WD
4WD
2WD
4WD
2WD
4WD
License Plate Number
USAGE INFORMATION
VEH. NO. 1
VEH. NO. 2
VEH. NO. 3
Annual Kilometers
Pleasure
Yes No
Yes No
Yes No
Business or Farm Use
Yes No
Yes No
Yes No
Daily KM One Way
Anti-Theft Device
Yes No
Yes No
Yes No
Current Insurance Company
Current Policy Number
Current Policy Expiry Date
dd/mm/yy
DRIVER INFORMATION
List ALL persons holding a valid Driver's
Licence in the household including YOURSELF
VEH. NO. 1
VEH. NO. 2
VEH. NO. 3
Driver Name
Relation To Applicant
Birth Date dd/mm/yy
Drivers License Number
Sex
Male
Female
Male
Female
Male
Female
Married
Yes No
Yes No
Yes No
Driver Training
Yes No
Yes No
Yes No
First Date Licensed In Canada mm/yy
Currently Insured In Canada For At
Least One Year?
Yes No
Yes No
Yes No
DISCLAIMER:
All information is held in strict confidence for rating purposes only.
No information is given or sold, other than to the insurance company
that issues your policy. Our quote is based solely on the accruacy and
completeness of the info you provide us. Companies verify all info and
may adjust premiums for any changes.
