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Auto Insurance
Name:
Address:
City:
Province:
Postal Code (X1Y 2Z3):
Phone Number (123-456-7890):
Email Address:
Date of birth of Principal Driver:
Date of G Licence:
Date of G1 and G2 Licence (dates, if applicable):
Driver’s training (date, if applicable):
How many years have you consistently had automobile insurance (or listed as a driver on someone else’s policy):
How many consecutive years of insurance with current company:
Current Insurance carrier & renewal date:
Additional drivers - Date of Birth and licence date details:
Additional drivers - Drivers training details:
Is vehicle used for business (if yes, please include details):
Yes
No
Details:
Distance used to commute to work (one way):
Any driving convictions in the past 3 years (include date & details):
Any licence suspension in the last 6 years:
Yes
No
Any claims in the past 10 years (include date & details):
Year, make and model of vehicle:
Do you use snow tires less than 6 years old:
Yes
No
Coverage preferred, Note: the Liability Limit is $2,000,000, The deductible is $500:
Collision
Comprehensive
All perils
Other
Additional vehicles details:
Have you ever been cancelled for non-payment within the last 3 years:
Yes
No
Has your policy lapsed for any other reason by the insurance company:
Yes
No
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