Auto Insurance Quote

Driver 1Driver 2
Driver Information
Name:
Date of Birth (dd/mm/yy):
Gender: Male   Female Male   Female
Marital Status: Married   Single Married   Single
Occupational Status:
Type of licence currently held:
When was this licence received (dd/mm/yy):
Did the driver ever hold a G2 licence: Yes   No Yes   No
When was this licence received (dd/mm/yy):
Did the driver ever hold a G1 licence: Yes   No Yes   No
When was this licence received (dd/mm/yy):
Has the licence been suspended in the last 6 years: Yes   No Yes   No
Has the driver had any tickets, accidents or claims: Yes   No Yes   No
Date of first accident:
Cause of first accident:
Date of second accident:
Cause of second accident:
Any insurance policy cancelled in the last 3 years: Yes   No Yes   No
What is the expiry date of the cancelled policy:
Is the driver currently insured as the primary driver
on a Canadian or US auto policy:		 Yes   No Yes   No
Who it your current insurance provider:
How many years has the driver had continuous
insurance in Canada/US:
Vehicle Information
What year is the vehicle:
What is the make of the vehicle:
What is the model of the vehicle:
Is the vehicle leased: Yes   No
When was the vehicle purchased:
About how many kilometers is it driven each year:
About how many kilometers is it driven to work
or school each day:
How many theft protection devices on the vehicle:
Policyholder Details
Name:
Address:
City:
Province:
Postal Code:
How long lived at the current address:
Home telephone number:
E-mail: