Name
Date of Birth MM - DD - YYYY
Email Address
Gender MaleFemale
Marital Status SingleMarried
Telephone #
Driver License #
Address with postal code
Occupation
G1 MM - DD - YYYY
G2 MM - DD - YYYY
G MM - DD - YYYY
Do you have a Driver Training Certificate? When? MM - DD - YYYY
Have you had any convictions in the last 3 years or has an insurer cancelled your insurance? Briefly Explain
Have you had any claims in the past 10 years?
Car year, made and model
Do you have winter tire on this vehicle ? yesno
When did you purchase your vehicle? MM - DD - YYYY
Purchase price of your vehicle?
NewUsed
Full coverageThird Party Liability
Are you driving the vehicle to work? yesno
How far from work (one way)
V.I.N #
How many kms do you drive each year?
Please retype the Human Verification code below exactly as it appears:
Who is driving this vehicle?
Who is occasional driver on this vehicle?
M1 MM - DD - YYYY
M2 MM - DD - YYYY
M MM - DD - YYYY
Have you had any motorcycle insurance claims in the past 10 years?
Motorcycle year, made and model
When did you purchase your motorcycle? MM - DD - YYYY
Purchase price of your motorcycle?
Are you driving the motorcycle to work? yesno
Gender malefemale
Telephone
When did you last replace the roof? MM - DD - YYYY
When did you last replace the furnace? MM - DD - YYYY
When did you last update the electrical? MM - DD - YYYY
When did you last update the plumbing? MM - DD - YYYY
When did you first get home insurance?
Square footage of the house (excluding the basement)
Does anyone in the house smoke? YESNO
When did you move into this house? or did you just purchase it?
Your Name *
Email Address *
SmokerNon Smoker
Phone #
Address
Coverage amount
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