Please Complete All Field Areas
Contact Information:
Your name:
E-Mail Address:
Home Tel: (###-###-####) Work Tel:
Addr: Line 1 (number & street name)
Line 2 (city, province, postal code)
Current Insurance Information:
Are You Insured Now? Yes No
***If "No", Have you been insured in the past?Yes No
Present Insurer (example: Economical Mutual Ins.)
Renewal Date
Driver #1 Information: *Note* Please list All drivers in your home separately.
Driver Name: D.O.B. (yyyy/mm/dd)
Male Female Married/Common-Law Single
Licensing Date: "G1" License Driver Training? Yes No
Licensing Date: "G2" License
Licensing Date: "G" License
Any Major/Minor Convictions in Past 3 Years? Yes No
If "YES", How many? One Two Three Four
Any At-Fault Accidents in Past 6 Years? Yes No
If "YES", How many? One Two Three Four
Please give details of Convictions & At-Fault Accidents. (yyyy/mm/dd and Type)
Driver #2 Information:
Driver Name: D.O.B. (yyyy/mm/dd)
Male Female Married/Common-Law Single
Licensing Date: "G1" License Driver Training? Yes No
Licensing Date: "G2" License
Licensing Date: "G" License
Any Major/Minor Convictions in Past 3 Years? Yes No
If "YES", How many? One Two Three Four
Any At-Fault Accidents in Past 6 Years? Yes No
If "YES", How many? One Two Three Four
Please give details of Convictions & At-Fault Accidents. (yyyy/mm/dd and Type)
Driver #3 Information:
Driver Name: D.O.B. (yyyy/mm/dd)
Male Female Married/Common-Law Single
Licensing Date: "G1" License Driver Training? Yes No
Licensing Date: "G2" License
Licensing Date: "G" License
Any Major/Minor Convictions in Past 3 Years? Yes No
If "YES", How many? One Two Three Four
Any At-Fault Accidents in Past 6 Years? Yes No
If "YES", How many? One Two Three Four
Please give details of Convictions & At-Fault Accidents. (yyyy/mm/dd and Type)
Vehicle #1 Information:
Year: Make: Model (2dr or 4dr?)
Liability BI/PD Limit:
Collision Deductible:
Comprehensive Deductible:
Option: Loss of Use (Rental Vehicle): Yes No Note: Collision Coverage must be in place for this benefit.
Commute To Work Distance (Kms. one way): Annual Kms. Driven:
Principal Operator of this vehicle:
Vehicle #2 Information:
Year: Make: Model (2dr or 4dr?)
Liability BI/PD Limit:
Collision Deductible:
Comprehensive Deductible:
Option: Loss of Use (Rental Vehicle): Yes No Note: Collision Coverage must be in place for this benefit.
Commute To Work Distance (Kms. one way): Annual Kms. Driven:
Principal Operator of this vehicle:
Vehicle #3 Information:
Year: Make: Model (2dr or 4dr?)
Liability BI/PD Limit:
Collision Deductible:
Comprehensive Deductible:
Option: Loss of Use (Rental Vehicle): Yes No Note: Collision Coverage must be in place for this benefit.
Commute To Work Distance (Kms. one way): Annual Kms. Driven:
Principal Operator of this vehicle:
Any additional comments?
