Personal Information

First Name:	Last Name:

City:
Postal Code:

Contact Information

Daytime Phone:	Ext.
Fax:
*E-mail:
Preferred method of contact:	Select Phone Fax E-mail

Insurance Information

Are you a client of ours?
	Yes No
	If yes, name of broker? Select Bill Frances Kathy Kona Martin Richard
Do you currently hold auto insurance elsewhere in Canada?
	Yes No
	If yes:	Province held in:
		Insurance Company (not broker):
		Policy Number (if possible):
Expiry date of current or last policy (mm/dd/yyyy)
How many years have you been continuously insured?
	Select Less than 1 year 1 year 2 years 3 years 4 years 5 years 6 years or greater
Has ANY insurance company cancelled any of your policies for any reason in the past 5 years?
	YesNo
	If yes,	please explain:
Do you own your own home or condo?
	YesNo

Driver Information

	Driver 1	Driver 2	Driver 3
Name:
Date of Birth (mm/dd/yyyy):
Sex:	Select Male Female	Select Male Female	Select Male Female
Marital status:	Select Married Single Common-law	Select Married Single Common-law	Select Married Single Common-law
Years licensed in Canada:	years	years	years
License Class:
Driver training in past 3 yrs?	YesNo	YesNo	YesNo
Occupation:
Any traffic convictions of ANY KIND in the past 3 years?
	YesNo	YesNo	YesNo
	If yes, list offence and approximate date of conviction:
Any claims of ANY KIND in past 6 years?
	YesNo	YesNo	YesNo
	If Yes, please complete Claim Information
License suspended AT ALL in the past 6 years?
	YesNo	YesNo	YesNo
	If yes, list effective dates and reason for the suspension:

Claim Information

		Date of Claim
	Type of Claim:	(mm/dd/yyyy)	Driver Involved:
1.	Select At-fault Collision Not-at-fault Collision Partial At-fault Collision Windshield/Vandalism/Theft		Select None Driver 1 Driver 2 Driver 3 Other Driver
2.	Select At-fault Collision Not-at-fault Collision Partial At-fault Collision Windshield/Vandalism/Theft		Select None Driver 1 Driver 2 Driver 3 Other Driver
3.	Select At-fault Collision Not-at-fault Collision Partial At-fault Collision Windshield/Vandalism/Theft		Select None Driver 1 Driver 2 Driver 3 Other Driver

Vehicle Information

	Vehicle 1	Vehicle 2	Vehicle 3
Year:
Make:
Model:
Style:	Select 2 Door 3 Door 4 Door 5 Door Station Wgn Sport Utility Pick-up Van	Select 2 Door 3 Door 4 Door 5 DoorStation Wgn Sport Utility Pick-up Van	Select 2 Door 3 Door 4 Door 5 Door Station Wgn Sport Utility Pick-up Van
Use:	Select Pleasure Only Commute < 5 km Commute 5-20 km Commute 20+ km Partial Business Business	Select Pleasure Only Commute < 5 km Commute 5-20 km Commute 20+ km Partial Business Business	Select Pleasure Only Commute < 5 km Commute 5-20 km Commute 20+ km Partial Business Business
Coverage Information
	Vehicle 1	Vehicle 2	Vehicle 3
Third Party Liability:	Select $200,000 $500,000 $1,000,000 $2,000,000	Select $200,000 $500,000 $1,000,000 $2,000,000	Select $200,000 $500,000 $1,000,000 $2,000,000
Collision:	Select None $250 deductible $500 deductible $1,000 deductible	Select None $250 deductible $500 deductible $1,000 deductible	Select None $250 deductible $500 deductible $1,000 deductible
Comprehensive:	Select None $100 deductible $250 deductible $500 deductible	Select None $100 deductible $250 deductible $500 deductible	Select None $100 deductible $250 deductible $500 deductible
Additional:	Loss of Use Non-Owned Auto Limited Waiver of Depreciation Emergency Service Expense	Loss of Use Non-Owned Auto Limited Waiver of Depreciation Emergency Service Expense	Loss of Use Non-Owned Auto Limited Waiver of Depreciation Emergency Service Expense

Other Information

Are there any other licensed operators in the household who are not listed here?
	YesNo
	If yes,	please explain why they are excluded:
Are there any other vehicles attached to your residence which are not listed here?
	YesNo
	If yes,	please explain why they are excluded:

Comments

Comment
Thank-you for taking the time to fill out this form.  Select the "Submit" button below and we will contact you by the next business day.  Our quote will include the coverages you selected.  We may include the cost of popular optional coverages with our quotation.