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Automotive Insurance Quote Request

Fill out the fields below:

Client Information

First Name - Required Information

Last Name - Required Information

Email - Required Information

Phone Number - Required Information

Address - Required Information

City - Required Information

Province - Required Information

Postal Code - Required Information

Vehicle Information




Date Purchased (mm/dd/yyyy):

Did you purchase the vehicle NewUsed?

Coverages Required

Check the coverages you require

1 Million Liability2 Million LiabilityCollisionComprehensive

Vehicle Use

Do you use the vehicle for PleasureWork?

What is the distance to work, one way in Kms?

How many Kms do you drive annually?

Do you use winter tires? YesNo

Do you qualify for a retiree discount? YesNo

Add a second vehicle

Information on Driver(s)

Required for all drivers on policy

Driver 1

First Name

Last Name

Marital Status SingleMarried

Date of Birth (mm/dd/yyyy)

Date G1 license obtained (mm/dd/yyyy)

Date G2 license obtained (mm/dd/yyyy)

Date G license obtained (mm/dd/yyyy)

Do you have any claims in the last 9 years either at-fault or not at-fault (this includes glass claims)? YesNo

Do you have any tickets (convictions) in the last 3 years? YesNo

Have you had your license suspended in the last 6 years? YesNo

Have you had insurance cancelled for non-payment in the last 3 years? YesNo

Have you ever been charged with fraud or material misrepresentation? YesNo

Do you have current auto insurance? YesNo

If Yes, how many years have you had continuous insurance?

Add a second driver

Please provide us with any special information you think we should know as we prepare your insurance quote.
Example: My mother is currently insured with your office.

Please note: You can receive an extra 15% discount on your auto if we insure your home with the same company.

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