To get a no obligation quote on your auto insurance, please complete the following form and submit it to our office.You will be contacted by the next business day.

Please note:
It is imperative that all fields be completed for us to give you an accurate quote.

You do not have to complete the entire form again if you want a quote for a different vehicle. Simply fill out the Vehicle 2 information area.

We can only provide insurance for residents of Ontario, Canada.

Contact Information

Home Phone:
Office Phone:	Ext.
Fax:
E-mail:

Insurance Information

Are you an existing client of ours?
	Yes No
	If yes, what type of insurance?   Auto   Home   Other
Have you ever had your insurance cancelled or refused?
	Yes No
Do you currently have insurance?
	Yes No
Expiry date of existing or last insurance policy (dd/mm/yyyy)
How many years have you had consecutive insurance?
	Select Less than 1 year 1 year 2 years 3 years 4 years 5 years 6 years or greater
Do you own your own home or condominium?
	Yes No

Drivers Information

	Driver 1	Driver 2	Driver 3
Name:
Age:	yrs old	yrs old	yrs old
Years licensed in Canada:	years	years	years
License Class:
Sex:	SelectMaleFemale	SelectMaleFemale	SelectMaleFemale
Marital status:	SelectMarriedSingleCommon-law	SelectMarriedSingleCommon-law	SelectMarriedSingleCommon-law
Driving school?	YesNo	YesNo	YesNo
Occupation:
Are you a graduate of any post-secondary institution in North America?
	YesNo	YesNo	YesNo
Minor traffic convictions in the past 3 years:	SelectNoneOneTwoThreeOver Three	SelectNoneOneTwoThreeOver Three	Select NoneOneTwoThreeOver Three
** minor violations include speeding, seatbelt, prohibited turn and other similar offences **
Major traffic convictions in the past 3 years:	SelectNoneOneTwoThreeOver Three	SelectNoneOneTwoThreeOver Three	SelectNoneOneTwoThreeOver Three
** major violations include impaired driving, careless driving, refusing breathalyzer & other similar offences**

Have any of the listed drivers had their license suspended or revoked in the past 3 years?
	YesNo
In the past 6 years, have any of the above drivers been involved in a car accident, or have any claims been made to your insurance company?
	YesNo If Yes, please complete Claims Information

Claims Information

		Date of Claim
	Type of Claim:	(mm/yyyy)	Driver Involved:
1.	SelectNoneAt-fault AccidentNot-at-fault AccidentPartial At-fault AccidentWindshield/Vandalism/Theft		SelectNoneDriver 1Driver 2Driver 3Other Driver
2.	Select None At-fault Accident Not-at-fault Accident Partial At-fault Accident Windshield/Vandalism/Theft		Select None Driver 1 Driver 2 Driver 3 Other Driver
3.	Select None At-fault Accident Not-at-fault Accident Partial At-fault Accident Windshield/Vandalism/Theft		Select None Driver 1 Driver 2 Driver 3 Other Driver

Vehicle Information

	Vehicle 1	Vehicle 2
Year:
Make:
Model:
Style:	Select2 Door2 Door Hatch4 Door4 Door HatchStation WgnSport UtilityPick-upVan	Select2 Door2 Door Hatch4 Door4 Door HatchStation WgnSport UtilityPick-upVan
Use:	SelectPleasure OnlyCommute < 5 kmCommute 6-15 kmCommute 16-25 kmCommute 26+ kmPartial BusinessBusiness	SelectPleasure OnlyCommute < 5 kmCommute 6-15 kmCommute 16-25 kmCommute 26+ kmPartial BusinessBusiness
How many Km do you drive per year:	Select< 5,000 km< 10,000 km< 15,000 km< 20,000 km< 25,000 km> 25,000 km	Select< 5,000 km< 10,000 km< 15,000 km< 20,000 km< 25,000 km> 25,000 km
Who is Primary Driver:	SelectDriver 1Driver 2Driver 3	SelectDriver 1Driver 2Driver 3
Do you currently own this vehicle?	Yes No	Yes No

Coverages & Deductibles

Liability:	Select $500,000 $1,000,000 $2,000,000	Select $500,000 $1,000,000 $2,000,000
	deductible	deductible
Collision:	Select $300 $500 $1,000	Select $300 $500 $1,000
	deductible	deductible
Comprehensive:	Select $100 $250 $300 $500 $1,000	Select $100 $250 $300 $500 $1,000
Do you require any of the following Additional Coverages?
Limited Glass Coverage Loss of Use + Rental car in case of an accident Non-Owned Auto Coverage Waiver of Depreciation Coverage (only available on new vehicles)

Comments

Comment
Thank-you for taking the time to fill out this form. Select the "Submit" button below and we will e-mail you a quote by the next business day.   Our quote will include the coverages you selected plus the standard Accident Benefits coverages. We will include the cost of popular optional coverages with our quotation. Optional Accident Benefit coverages can be upgraded by consulting one of our brokers.