Auto Insurance

Fields marked by an asterisk (*) are required fields.
CONTACT INFORMATION
Privacy Consent: By completing this form, you are giving us permission to use your information for the purpose of providing an insurance quote, council or risk management service. Please read our Privacy Statement for more information.
Your Name	* Name
Address	* Address
City (Ontario Residents Only)	* City
Postal Code	* Postal Code
Home Number
Business Phone Number
Cell Number
Fax Number
Email Address	*
How many consecutive years have you had insurance in Canada or the US?	No current insurance Less than 1 year 1 year 2 years 3 years 4 years 5 or more years  *
Current Insurer enter 'None' if no current insurance	*
If no current insurance, what is the reason?
Expiry Date/Date Insurance Required	* Expiry Date/Date Insurance Required
What is your current annual premium?
Do you presently have home insurance?	Yes No
Why are you looking for a new insurer or broker?	Not happy with price Not happy with service Issues with a claim settlement Not sure Other
How did you hear about us?	Google Other search engine Referral from a friend Other website Advertisement Not sure Other
Additional Comments
DRIVER ONE INFORMATION
Date of Birth	* Driver 1 Birth MonthDriver 1 Birth DayDriver 1 Birth Year
Gender	Male Female  *
Marital Status	Married Single  *
Date G, G2, and/or G1 Licence Obtained *
G Licence Date
G2 Licence Date
G1 Licence Date
Do you have a driver's training certificate?	Yes No  *
Have you had insurance coverage cancelled by an insurance company in the last 3 years?	Yes No  *
How many traffic tickets (not parking tickets) have you had in the last 3 years?	0 1 2 3 More than 3  *
How many claims have you had in the past 6 years?	0 1 2 3 More than 3  *
Details of claims and/or convictions if any. Include date, description, and amount paid out (for claims).
DRIVER TWO INFORMATION
Date of Birth
Gender	Male Female
Marital Status	Married Single
Date G Licence Obtained
Date G2 Licence Obtained
Date G1 Licence Obtained
Do you have a driver's training certificate?	Yes No
Have you had insurance coverage cancelled by an insurance company in the last 3 years?	Yes No
How many traffic tickets (not parking tickets) have you had in the last 3 years?	0 1 2 3 More than 3
How many claims have you had in the past 6 years?	0 1 2 3 More than 3
Details of claims and/or convictions if any. Include date, description, and amount paid out (for claims).
VEHICLE ONE INFORMATION
Year	*
Make	*
Model (please be specific)	*
Use of Vehicle	Pleasure Commute to Work
Estimated Annual Kilometres	*
Number of kilometres to work one way	*
Third Party Liability (choose a limit)	$1,000,000 $2,000,000  *
Collision (choose a deductible)	Not required $500 $1,000 $2,000
Comprehensive (choose a deductible)	Not required $500 $1,000 $2,000
VEHICLE TWO INFORMATION
Year
Make
Model (please be specific)
Use of Vehicle	Pleasure Commute to Work
Estimated Annual Kilometres
Number of kilometres to work one way
Third Party Liability (choose a limit)	$1,000,000 $2,000,000
Collision (choose a deductible)	Not required $500 $1,000 $2,000
Comprehensive (choose a deductible)	Not required $500 $1,000 $2,000
You must fill all required fields.