Auto Quote Application

Please fill out and send us the form below and we will provide you with a detailed auto insurance quotation.

1

APPLICANT'S NAME & POSTAL ADDRESS

NAME

ADDRESS     CITY     POSTAL CODE

PHONE NO. HOME     WORK

EMAIL ADDRESS

LESSOR (if applicable) a lessor is someone you lease the vehicle from

NAME

ADDRESS     CITY     POSTAL CODE

PHONE NO. HOME     WORK

2

POLICY PERIOD (all times are local times at the applicant's address shown above)

EFFECTIVE/RENEWAL DATE (YYYY/MM/DD)

EXPIRY DATE (YYYY/MM/DD)

3

DESCRIBED AUTOMOBILE
(Each automobile will be used primarily in the vicinity of the applicant's address, unless otherwise stated in the Comments section)

AUTO NO.

MODEL YEAR

MAKE OR TRADE NAME

MODEL

BODY TYPE

NO. OF CYLINDERS OR ENGINE SIZE

GROSS VEHICLE WEIGHT
 

1.
2.
3.

AUTO NO.

VEHICLE ID NO. (SERIAL NO.)

OWNED?

LEASED?

PURCHASED/LEASED

PURCHASE PRICE (including options & taxes)

AUTOMOBILE USE (Give details in Comments section at the end)

year month new? used? Pleas Commute 1 Way km Bussiness Farm Comm.



AUTO NO.

ESTIMATED ANNUAL DRIVING DISTANCE

IS ANY AUTOMOBILE USED FOR CAR POOLING? If yes, give # of Passengers & details

TYPE OF FUEL USED

UNREPAIRED DAMAGE

MODIFIED/ CUSTOMIZED?

GAS

DIESEL

IF OTHER GIVE DETAILS

1.

2.

3.

AUTO NO.

LIENHOLDER NAME & POSTAL ADDRESS

1.

   

2.

   

3.

   

Is the applicant both the Registered Owner and the Actual Owner of the described automobile(s)?    
If No, pleased give details

Will any of the described automobiles be rented or leased to others, or used to carry passengers for compensation or hire, or haul a trailer, or carry explosives or radioactive material?    

Total number of automobiles in the household or business.

4

DRIVER INFORMATION List all drivers of the described automobile(s) in the houshold or business.

DRIVER NO.

NAME AS SHOWN ON DRIVER'S LICENCE

DRIVER'S LICENCE NUMBER

DATE OF BIRTH
(YYYY/MM/DD)

SEX

MARITAL STATUS

1.

2.

3.

4.

DRIVER NO.

DO YOU HAVE A DRIVER TRAINING CERTIFICATE?

DATE FIRST LICENCED IN CANADA OR U.S. (Class G or equivalent)

OTHER CLASS OF LICENCE, IF ANY

PERCENTAGE USE BY EACH DRIVER

Are any other persons in the household or business licenced to drive?

Do any drivers qualify for Retiree Discount?

CLASS

YEAR

MONTH

CLASS

YEAR

MONTH

Auto 1

Auto 2

Auto 3

1.

2.

If yes please provide details in the Comments section

 

3.

4.

If a driver licenced less than 6 years is Canada, driving experience in other countries may be recognized. What are the details of the applicant's most recent automobile insurance?

INSURANCE COMPANY     POLICY NO.    EXPIRY DATE (yyyy/mm/dd)

TO THE APPLICANT'S KNOWLEDGE

Has any driver's licence, vehicle permit etc, issued to the applicant or to any person in the household or business been suspended or cancelled in the last 6 years?
 If Yes, give details

Has any insurance company cancelled automobile insurance for the applicant or any listed driver in the last 3 years?
 If Yes, give details

During the last 3 years, has any automobile insurance policy issued to the applicant or any listed driver been cancelled or has any claim been denied for material misrepresentation?
 If Yes, give details

Has the applicant or any listed driver been found by a court to have commited a fraud connected with automobile insurance?
 If Yes, give details

5

PREVIOUS ACCIDENTS & INSURANCE CLAIMS

Give details of all accidents or claims arising from the ownership, use or operation of any automobile by the applicant or any listed driver during the last 6 years. The coverages are: BI - Bodily Injury, PD - Property Damage, AB - Accident Benefits, DCPD - Direct Compensation - Property Damage, UA - Uninsured Automobile, Coll - Collision, AP - All Perils, Comp - Comprehensive, SP - Specified Perils

DRIVER NO.

AUTO NO.

DATE (YYYY/MM/DD)

COVERAGE CLAIM PAID UNDER

AMOUNT PAID OR ESTIMATE

DETAILS (Use Comments section if necessary)

YEAR

MONTH

DAY

BI

PD

AB

DCPD

UA

Coll/AP

Comp/SP

1.

2.

3.

4.

6

HISTORY OF CONVICTIONS

Give details of all convictions of the applicant and any listed driver arising from the operation of any automobile in the last 3 years.

DRIVER NO.

DATE CONVICTED
(YYYY/MM/DD)

DETAILS
(Use Comments section if necessary)

1.

2.

3.

7

RATING INFORMATION - For Company Use Only



8

INSURANCE COVERAGES APPLIED FOR - List all drivers of the described automobile(s) in the houshold or business.

AUTOMOBILE 1

LIABILITY

LIMIT (000's)

PREMIUM

BODILY INJURY / PROPERTY DAMAGE

ACCIDENT BENEFITS (Standard Benefits)

OPTIONAL INCREASED ACCIDENT BENEFITS
(You can check any of the options below which you do require)

   

Income Replacement

Caregiver, Housekeeping & Home Maintenance

Medical & Rehabilitation ($100,000) & Attendant Care ($1,072,000)

Death & Funeral

Dependant Care

Indexation Benefit (Consumer Price Index)

UNINSURED AUTOMOBILES

DEDUCTIBLE

PREMIUM

DIRECT COMPENSATION-PROPERTY DAMAGE The policy contains a partial payment of recovery clause for property damage if a deductible is specified for Direct Compensation-Property Damage



LOSS OR DAMAGE *

DEDUCTIBLE

PREMIUM

SPECIFIED PERILS (excluding Collision or Upset)

COMPREHENSIVE (excluding Collision or Upset)

COLLISION OR UPSET

ALL PERILS

* This policy contains a partial payment of loss clause. A deductible applies for each claim except as stated in your policy.

AUTOMOBILE 2

LIABILITY

LIMIT (000's)

PREMIUM

BODILY INJURY / PROPERTY DAMAGE

ACCIDENT BENEFITS (Standard Benefits)

OPTIONAL INCREASED ACCIDENT BENEFITS
(You can check any of the options below which you do require)

   

Income Replacement

Caregiver, Housekeeping & Home Maintenance

Medical & Rehabilitation ($100,000) & Attendant Care ($1,072,000)

Death & Funeral

Dependant Care

Indexation Benefit (Consumer Price Index)

UNINSURED AUTOMOBILES

DEDUCTIBLE

PREMIUM

DIRECT COMPENSATION-PROPERTY DAMAGE The policy contains a partial payment of recovery clause for property damage if a deductible is specified for Direct Compensation-Property Damage



LOSS OR DAMAGE *

DEDUCTIBLE

PREMIUM

SPECIFIED PERILS (excluding Collision or Upset)

COMPREHENSIVE (excluding Collision or Upset)

COLLISION OR UPSET

ALL PERILS

* This policy contains a partial payment of loss clause. A deductible applies for each claim except as stated in your policy.

AUTOMOBILE 3

LIABILITY

LIMIT (000's)

PREMIUM

BODILY INJURY / PROPERTY DAMAGE

ACCIDENT BENEFITS (Standard Benefits)

OPTIONAL INCREASED ACCIDENT BENEFITS
(You can check any of the options below which you do require)

   

Income Replacement

Caregiver, Housekeeping & Home Maintenance

Medical & Rehabilitation ($100,000) & Attendant Care ($1,072,000)

Death & Funeral

Dependant Care

Indexation Benefit (Consumer Price Index)

UNINSURED AUTOMOBILES

DEDUCTIBLE

PREMIUM

DIRECT COMPENSATION-PROPERTY DAMAGE The policy contains a partial payment of recovery clause for property damage if a deductible is specified for Direct Compensation-Property Damage



LOSS OR DAMAGE *

DEDUCTIBLE

PREMIUM

SPECIFIED PERILS (excluding Collision or Upset)

COMPREHENSIVE (excluding Collision or Upset)

COLLISION OR UPSET

ALL PERILS

* This policy contains a partial payment of loss clause. A deductible applies for each claim except as stated in your policy.

9

COMMENTS SECTION

Please use this space if you have further details.

10

SECURITY CODE

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