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Insurance Representative Information

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.