 |
|
| Name: |
|
| Address: |
|
| City: |
|
| Province: |
|
| Postal Code: |
|
| Phone Number: |
|
| Email Address: |
|
| Have you ever had insurance cancelled or refused? |
|
| If yes, please choose: |
|
| Expiry/Renewal Date: |
|
| Existing/Prior
Insurance Company Name: |
|
| Existing/Prior Policy Number: |
|
| Driver(s) Information: |
|
| Name: |
|
| Date of Birth: |
|
| Driver's License Number: |
|
| License class: |
|
|
|
|
|
|
G, G2 & G1 license dates:
(mm/yyyy) |
|
| Sex: |
|
|
|
|
|
|
| Marital status: |
|
|
|
|
|
|
| Driver training certificate: |
|
|
|
|
|
|
| Retired? |
|
|
|
|
|
|
| Number of Minor convictions in the last 3 years: |
|
|
|
|
|
|
| Number of Major convictions in the last 3 years (careless or impaired driving, refusing breathalyzer, etc.): |
|
|
|
|
|
|
| Have any of above drivers had their licenses suspended or revoked in the past 3 years? |
|
|
|
|
|
|
| Have any of the drivers above had accidents or insurance claims in the past 6 years? |
|
| Claims Information: |
| Claims |
Date (mm/yyyy) |
Driver involved |
|
| #1: |
|
| #2: |
|
| #3: |
|
| |
|
| Vehicle Information: |
|
| Vehicle make: |
|
| Year: |
|
| Model: |
|
| Style: |
|
|
|
|
| Use: |
|
|
|
|
| Kilometres driven per year: |
|
|
|
|
| Who is primary driver: |
|
|
|
|
| |
|
| Coverage Required: |
|
| Liability: |
|
|
|
|
| Collision deductible: |
|
|
|
|
| Comprehensive deductible: |
|
|
|
|
| |
|
| |
Disclaimer |
