Car Insurance Application Submission of this information does not represent a binding of any insurance contract or agreement. Additional information may be required in order to get an accurate quote of insurance. Step 1 of 3 33% Let Us Know Which Car You DriveYear202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000Make*Model*How Many KM Do You Drive to Work 1-WayKM 1-WayThis includes going to work or bus/subway station.How Many KM Do You Drive AnnuallyAnnual KM*Date Vehicle Purchased*Will The Car Have Winter Tires Installed From Nov 1 – March 31* Yes No Who Is The Primary Driver?Name First Last Date of BirthMM-DD-YYYYWhat Kind of License Do You Have? G G1 G2 Other What Age Did You Get Your First Driver's License?What Age Did You Get Your G2 License?What Age Did You Get Your G License?Postal Code*Postal Code of Where The Vehicle Is Normally Garaged/ParkedHow Long Have You Had Car Insurance Without InterruptionLess Than A Year1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years+Please Tell Us About Your Driving Record Please add any ticket,s claims, accidents or cancellations you may have hadAdd Tickets Yes No Such As: Speeding, Distracted Driving..etcTell Us Which Tickets You Have And When You Got ThemAdd Cancellation Yes No Such As: Non-Payment of Premium, Medical Reason, Non-Disclosure..etcPlease Tell Us When Policy Was Cancelled and For What ReasonAdd License Suspension Yes No Such As: Alcohol/Drug Related, Demerit Points or Convictions..etcPlease Tell Us What Day Your License Was Suspended, For What Reason and When It Was or Will It Be ReinstatedAdd At Fault Accident Yes No Such As Hitting an Object, Hitting Another Vehicle ..etcPlease Tell Us The Date of The Accident and Type of AccidentAdd Not At Fault Accident Yes No Collisions..etcPlease Tell Us The Date of The Accident and Type of AccidentAdd Other Claims Yes No Such as hitting a deer, windshield damage, theft of vehicle or fire.Please Tell Us About Any Other Claims You May HaveAre You Currently Insured? Yes No Date Your Current Policy ExpiresAre There Any Other Licensed Drivers Living In The Household? Yes No Your Contact Info Phone NumberEmail AddressConsent* I agree to the Privacy Policy and acknowledge the Disclosure Statement.
