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Automobile Insurance Quote Request

* indicates a required field.

Contact Information:

Name: *	Address:
Telephone: * (ex: 999-999-9999)	Address:
Email:	City:	Province:	Postal Code: *
My auto insurance expires on (mm/dd):	Comments:
My home insurance expires on (mm/dd):	Comments:

Described Automobile(s): *

	Model Year (YYYY)	Make	Model	# Doors	# Cylinders
Auto 1: *
Auto 2:

Automobile(s) Use:

	Is Auto Driven to work?	If so, distance one way?	Is auto used for business?
Auto 1:	Yes No	km	Yes No
Auto 2:	Yes No	km	Yes No

Driver Information: *

	Date of birth (DD/MM/YYYY)	Date First Licensed in Canada(DD/MM/YYYY)	Percentage of Use	Male / Female
Auto 1: *
Auto 2:

Traffic Tickets (other than parking): *

Yes No

If Yes:

List date(s) and infraction(s):

Accidents or Claims: *

Has any driver been involved in an "AT FAULT ACCIDENT(S)" within the past 6 years?

Yes No

If Yes:

List date(s) of the accident(s):

Name of driver:

Auto involved or its substitute:

Has there been more than one insurance claim per vehicle insured during the past 6 years?
Yes No

Remarks & Additional Information Section:

(please use this space freely for questions, concerns or recommendations)

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WARNING: THE PRECEDING QUESTIONS DO NOT CONSTITUTE AN APPLICATION FOR AUTOMOBILE INSURANCE. THE QUESTIONS ARE SIMPLY A MEANS TO ARRIVE AT AN ESTIMATE OF INSURANCE COST BASED ON A MINIMUM AMOUNT OF INFORMATION

OUR AUTOMOBILE INSURANCE PACKAGE INCLUDES: (UNLESS OTHERWISE STATED)
$1,000,000 LIABILITY, BASIC ACCIDENT BENEFITS, UNINSURED AUTOMOBILE, NO DEDUCTIBLE - DIRECT COMPENSATION - PROPERTY DAMAGE, $500 DEDUCTIBLE COLLISION, $300 DEDUCTIBLE COMPREHENSIVE, OPCF 44 - FAMILY PROTECTION COVERAGE, OPCF 20 – LOSS OF USE COVERAGE - $900 TOTAL LIMIT