Car Insurance Home Insurance Boat Insurance Business Insurance Group Benefits Life and Disability Other   Car Insurance Name: Address: City: Province: Postal Code: (X1Y 2Z3) Phone Number: (123-456-7890) Email Address: (xxx@yyyy.zzz) Have you ever had insurance cancelled or refused? Yes     No Do you currently insure your car? Yes     No If not, have you had insurance for 12 consecutive months within the last 6 years? Yes     No When should coverage start? (dd/mm/yyyy) Driver(s) Information: #1 #2 #3 Name of Driver: Date of Birth: Drivers License #: Years licensed in Canada: License class: G G1 G2 G G1 G2 G G1 G2 Sex: Male Female Male Female Male Female Marital status: Married Single Common-law Married Single Common-law Married Single Common-law Driving school: Yes No Yes No Yes No Retired? Yes No Yes No Yes No Minor traffic convictions in the last 3 yrs: 0 1 2 3 More than 3 0 1 2 3 More than 3 0 1 2 3 More than 3 Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.): 0 1 2 3 More than 3 0 1 2 3 More than 3 0 1 2 3 More than 3 Are you currently insured? Yes     No Name of previous insurance company: Have any of above drivers had their licenses suspended or lapsed in the past 6 years? Yes     No Have any of the drivers above had accidents or claims in the past 10 years? Yes     No Claims Information: Claims Date (mm/yyyy) Driver involved #1: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3 #2: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3 #3: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3     Vehicle Information: Vehicle #1 Vehicle #2 Vehicle make: Year: Model: Style: 2-door 2-door hatch 4-door 4-door hatch Wagon SUV Pick up Van 2-door 2-door hatch 4-door 4-door hatch Wagon SUV Pick up Van Use: Commute Pleasure Only Business Commercial Commute Pleasure Only Business Commercial KM driven one way to work: Kilometres driven per year: 0-5000 5001-10000 10001-15000 15001-20000 20001-25000 over 25000 0-5000 5001-10000 10001-15000 15001-20000 20001-25000 over 25000 Who is primary driver: N/A Driver #1 Driver #2 Driver #3 N/A Driver #1 Driver #2 Driver #3     Coverage Required: Vehicle #1 Vehicle #2 Liability: $200,000 $500,000 $1,000,000 $2,000,000 $200,000 $500,000 $1,000,000 $2,000,000 Collision deductible: $300 $500 $1,000 $300 $500 $1,000 Comprehensive deductible: $100 $300 $500 $1,000 $100 $300 $500 $1,000   Disclaimer