Auto Insurance

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Contact Information

Your Name* Address* City* Postal Code* Email* Confirm Email* Phone Number Current Insurer Expiry Date 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 For how many continuous years have you had auto insurance?* Less than 1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10+ years Do you have A Home, Tenants or Condo policy as well? No Homeowner Tenants Condo Other

Driver Information

Driver #1

Name* Date of Birth* Sex* M F Marital Status* Single Married Common Law Widowed Other License Class* G G2 G1 M M2 M1 Other

Driver #2

Name Date of Birth Sex M F Marital Status Single Married Common Law Widowed Other License Class G G2 G1 M M2 M1 Other

If any driver went through the Graduated License Program please enter:

Date of G1, G2 and G Do you have a Driver Training Certificate? Yes No Has your coverage ever been cancelled (if yes, please explain)?* Yes No Convictions?* None 1 2 3+ Claims in the past 6 years?* None 1 2 3+

Vehicle(s) Information

Year* Make & Model (i.e. BMW X5 4.4i)* Use* Pleasure Commute Business Other If Commuting – Distance Driven 1 way to work Approximate Annual Kilometers Driven* Is the Vehicle Leased or Owned? Leased Owned

Additional Details

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