Let's start with your vehicle. What year, make and model do you drive?
How Many KM Do You Drive to Work 1-Way
How Many KM Do You Drive Annually
Month & Year You Purchased the Vehicle
Who is The Primary Driver Name
First Name
Last Name
Date of Birth
MM-DD-YYYY
What month and year did you obtain your G1 licence? (MM/YYYY)
Leave blank if you never held a G1 licence.
What month and year did you obtain your G2 licence? (MM/YYYY)
Leave blank if you never held a G2 licence.
What month and year did you obtain your G licence? (MM/YYYY)
Leave blank if you not yet obtained G License
Postal Code
Postal Code of Where The Vehicle Is Normally Garaged/Parked
How Many Years Have You Had Car Insurance Without Interruption?
Do You Have Any Tickets
Yes
No
Tell Us Which Tickets You Have And the Date You Got Them
Do You Have Any Cancellations?
Yes
No
Such as non-payment of premium, missed payment, non-disclosure, claims history, or another reason.
Please tell us the date of each cancellation, the insurer involved, and the reason for cancellation.
Do You Have Any Suspensions?
Yes
No
Such As: unpaid fines, demerit points, impaired driving, distracted driving, medical reasons, or another reason.
Please tell us the date of each licence suspension, the reason, and the date your licence was reinstated or is expected to be reinstated. Examples: unpaid fines, demerit points, impaired driving, distracted driving, medical reason, or another reason.
Do You Have Any At Fault Accidents?
Yes
No
Such As Hitting an Object, Hitting Another Vehicle ..etc
Please tell us the date of each at-fault accident, briefly describe what happened, and confirm whether the claim is closed or still open.
Do You Have Any Not At Fault Accidents?
Yes
No
Such as a collision where another driver was found responsible.
Please tell us the date of each not-at-fault accident, briefly describe what happened, and confirm whether the claim is closed or still open.
Do You Have Any Other Claims?
Yes
No
Such as hitting a deer, windshield damage, theft of vehicle or fire.
Please tell us the date of each other claim, the type of loss, and confirm whether the claim is closed or still open.
Are You Currently Insured?
Yes
No
Date Your Current Policy Expires
Are There Any Other Licensed Drivers Living In The Household?
Yes
No
Please Provide your Phone Number
Please Provide Your Email Address:
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