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Auto Insurance
Name:
Address:
City:
Province:
Postal Code: (X1Y 2Z3)
Phone Number: (123-456-7890)
Email Address: (xxx@yyyy.zzz)
Date of Birth of principal driver: (mm/dd/yyyy)
Marital status of principal driver:
Date Received G1 license:
Date Received G2 license:
Date Received G license:
Any driving convictions
in past 3 years?
  
If so (# of convictions):
If so (dates of convictions):
Vehicle Information
Do you use your vehicle
for business?
  
If yes, how many kms per yer:
Do you use your vehicle to commute to and from work?   
If yes, how many kms one way:
Year, make and model of vehicle:
Coverage Requested
Liability limit requested:
Coverage Preferred:
Deductible:
Vehicle Purchase Date(mm/dd/yyyy):
Vehicle Purchase Price:
Additional vehicles to be quoted?   
How many years have you consistently had an auto policy in force or been listed on someone else’s policy as a listed driver?*
Number of at fault claims in the past 10 years?*
How many years since
last at fault claim
(if within 10 years)*
How many years since
last claim
(if within 10 years)*
What is your occupation?*
Was your prior policy canceled for non payment?*
Was your policy lapsed for any other reason by the insurance company?*
Which insurance company has your current property insurance?*
Underage Driver Information
Gender of additional drivers under 25 years of age:
Do driver(s) under 25 years of age have driver training certification?   
Any driving convictions
in past 3 years?
  
If so (# of convictions):
If so (dates of convictions):
Number of at fault claims in the past 10 years?*
How many years since
last at fault claim
(if within 10 years)*
   
 




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