| 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. |