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| CONTACT INFORMATION |
| I give permission for my information to be used for the purpose of providing and insurance quote, council or risk management service*
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| Your Name | *
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| Address | *
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| City (Ontario Residents Only) | *
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| Postal Code | *
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| Home Number | |
| Business Phone Number | |
| Cell Number | |
| Fax Number | |
| Email Address |
* |
| How many consecutive years have you had insurance in Canada or the US? | * |
| Current Insurer enter 'None' if no current insurance | * |
| If no current insurance, what is the reason? | |
| Expiry Date/Date Insurance Required | *
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| What is your current annual premium? | |
| Do you presently have home insurance? | |
| Why are you looking for a new insurer or broker? | |
| How did you hear about us? | |
| Additional Comments |
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| DRIVER ONE INFORMATION |
| Date of Birth | *
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| Gender | *
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| Marital Status | *
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| Date G, G2, and/or G1 Licence Obtained*
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| G Licence Date | |
| G2 Licence Date | |
| G1 Licence Date | |
| Do you have a driver's training certificate? | *
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| Have you had insurance coverage cancelled by
an insurance company in the last 3 years?
| *
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| How many traffic tickets (not parking
tickets) have you had in the last 3 years?
| *
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| How many claims have you had in the past 6
years? | *
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| Details of claims and/or convictions if any. Include date, description, and amount paid out (for claims). | |
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| DRIVER TWO INFORMATION |
| Date of Birth | |
| Gender | |
| Marital Status | |
| Date G Licence Obtained | |
| Date G2 Licence Obtained | |
| Date G1 Licence Obtained | |
| Do you have a driver's training certificate? | |
| Have you had insurance coverage
cancelled by an insurance company in the last 3 years?
| |
| How many traffic tickets (not
parking tickets) have you had in the last 3 years?
| |
| How many claims have you had in the past 6 years? | |
| Details of claims and/or convictions if any. Include date, description, and amount paid out (for claims). | |
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| VEHICLE ONE INFORMATION |
| Year | *
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| Make | *
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| Model (please be specific) | *
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| Use of Vehicle |
* |
| Estimated Annual Kilometres | *
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| Number of kilometres to work one way | *
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| Third Party Liability (choose a limit) |
* |
| Collision (choose a deductible) |
* |
| Comprehensive (choose a deductible) |
* |
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| VEHICLE TWO INFORMATION |
| Year | |
| Make | |
| Model (please be specific) | |
| Use of Vehicle | |
| Estimated Annual Kilometres | |
| Number of kilometres to work one way | |
| Third Party Liability (choose a limit) | |
| Collision (choose a deductible) | |
| Comprehensive (choose a deductible) | |
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