Your Car |
Make: |
Model: |
Year: |
Distance driven one way to work: |
Annual mileage: |
Do you use your car for business? Yes or No |
Vehicle Identification Number (VIN): |
Your Current Broker, Agent, or Insurance Company and Coverages/Deductibles and Rates |
Name: |
Company: |
Phone: |
Insurance policy number: |
Coverage: |
Deductibles: |
Your current annual insurance rate: |
You (as principal driver) |
Gender: |
Birth Date: |
Marital Status: |
Number of years you have been licensed to drive in Canada or the U.S.: |
Your driver's licence number: |
Has your policy ever been cancelled for non-payment or any other reason? |
First-time driver: |
Did you receive a Driver Training Certificate? Yes or No |
List details of all accidents and claims in the past 6 years: |
List details of all traffic violations (not including parking tickets) in the past 3 years: |
Coverages: |
Deductibles: |
Other (Occasional) Drivers |
Gender: |
Birth Date: |
Marital Status: |
Number of years licensed to drive in Canada or the U.S.: |
Date of receiving G1, G2 and G license: |
Did they receive driver training? Yes or No |
Do they have a Driver Training Certificate? Yes or No |
List details of all accidents and claims in the past 6 years. |
List details of all traffic violations (not including parking tickets) in the past 3 years. |