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Car Insurance
Click here to obtain an instant online quote. Otherwise, you can complete this form and a broker will email or call you with a competitive price quotation.
If you have a group code number, please enter it here:
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Have you ever had insurance cancelled or refused?   
Do you currently insure
your car? 		  
If not, have you had insurance for 12 consecutive months within the last 6 years?   
When should coverage start? (dd/mm/yyyy)
 
Driver(s) Information #1 #2 #3
Name of Driver:
Date of Birth:
Drivers Licence#:
Years licensed in Canada:
License class:
Sex:
Marital status:
Driving school:
Retired?
Minor traffic convictions
in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
Are you currently insured?   
Name of previous insurance company:
Have any of above drivers had their licenses suspended or lapsed in the past 6 years?   
Have any of the drivers above had accidents or claims in the past 10 years?   
 
Claims Information  
#1:
Type of Claim:
Date: (mm/yyyy)
Driver Involved: 
#2:
Type of Claim:
Date: (mm/yyyy)
Driver Involved: 
#3:
Type of Claim:
Date: (mm/yyyy)
Driver Involved: 
 
Vehicle Information Vehicle #1 Vehicle #2  
Vehicle make:  
Year:  
Model:  
Style:  
Use:  
KM driven one way to work:  
Kilometres driven per year:  
Who is primary driver:  
 
Coverage Required Vehicle #1 Vehicle #2  
Liability:  
Collision deductible:  
Comprehensive deductible:  
 
 

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