Auto Quote Form

Auto No.	Estimated Annual Driving Distance
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Is the applicant both the registered Owner and the Actual Owner of the desribed automobile(s)?
If NO, give details:
Will any of the described automobiles be rented or leased to others, or used to carry passengers for compensation or hire, or haul a trailer, or carry explosives or radioactive material?
If YES, give details:
Total number of automobiles in the household or business.

Driver Information - List all drivers of the described Automobile(s) in the household or business.
Driver No.	Name as shown on Driver's Licence	Driver's Licence Number	Date of Birth Year Month Day	Sex	Marital Status
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Are any other persons in the household or business licensed to drive?
Driver No.	Driver Training certificate attached	Date First Licensed in Canada Class Year Month	Percentage Use by Each Driver Auto 1 Auto 2 Auto 3	Is the principle driver of auto retired?
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If a driver is licensed less than 6 years in Canada, driving in other countries may be recognized. Please provide the details of the applicants most recent automobile insurance.
Insurance Company	Policy No.
Expiry Date: Year Month Day

To the best of the applicant's knowledge.

Has any driver's licence, vehicle permit etc. issued to a person in the household or business been suspended or cancelled in the last 6 years?
If yes give details:
Has any insurance company cancelled automobile insurance for the applicant or any listed driver in the last 3 years?
If yes give details:
During the last 3 years, has any automobile insurance policy issued to the applicant or any listed driver been cancelled or has any claim been denied for material misrepresentation?
If yes give details:
Has the applicant or any listed driver been found by a court to have committed a fraud connected with automobile insurance?
If yes give details:

Previous Accidents and Insurance Claims
Give details of all accidents or claims arising from the ownership, use or operation of any automobile by the applicant or any listed driver during the last 6 years.
#	Driver No.	Auto No.	Date Year Month Day	Type of Claim	Amount Paid or Estimate
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History of Convictions
Give Details of all convictions of the applicant and any listed driver arising from the operation of any automobile in the last 3 years.
Driver No.	Date Convicted Year Month Day	Details	Driver No.	Date Convicted Year Month Day	Details

Coverages Required (Mandatory)
Vehicle #	Liability	Accident Benefits	Property Deductible Damage	Uninsured Motorist
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Coverages Required Loss or Damage (Optional)
Vehicle	Collision Deductable	Comprehensive Deductable	Rental Car	Collision Coverage Required
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Payment Option

Applicant's Name & Postal Address	Lessor (if applicable)
Name:	Name:
Address:	Address:
Postal Code Country	Postal Code Country
Phone: Work Home	Phone: Fax:
E-Mail	E-Mail

Described Automobile - Each automobile will be used primarily in the vicinity of the applicant's address, unless otherwise stated in Remarks.
Auto No.	Model year	Make or Trade Name	Model	Body Type
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Auto No.	Vehicle Identification No. (Serial No.)	Owned / leased	Pleasure Use KM	Commute One - Way Use KM	Business KM	Farm KM	Commercial KM
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