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Client Name:
Phone NO:
Effective Date:
Address (Inc Postal Code):
PLEASE COMPLETE ONE FORM PER VEHICLE
Year Make & Model of vehicle:
Number of doors:
Use of Vehicle (ie: pleasure, to and from work/school)
Kms one way to work:
Annual kms:
Name of Principal Driver:
Date of birth:
Marital Status:
Single
Married
Divorced
Widowed
Years licenced (Canada):
Years licenced (Other):
Where:
Class of licence:
G
G1
G2
How long, if applicable: G1:
G2:
Do you have Driver Training:
Yes
No
Previous insurance:
Yes
No
How Long:
Any lapse in coverage:
Yes
No
How Long:
Reason:
Any violations (tickets):
Year and Type:
Any accidents:
Year and brief description:
Coverages Required:
OTHER DRIVERS (IF ANY)
Name of Other Driver:
Date of birth:
Marital Status:
Single
Married
Divorced
Widowed
Years licenced (Canada):
Years Licensed (Other):
Class of licence:
G
G1
G2
G2:
How long, if applicable: G1:
Do you have Driver Training:
Yes
No
Any lapse in coverage:
Yes
No
How long:
Reason:
Any accidents:
Yes
No
Year and brief descripton:
Any violations (tickets):
Yes
No
Year and type:
Over
40
years in business serving all of eastern Ontario and west Quebec
Liability
Collison
Comprehensive
2
3
4
5
N/A
km
km
E-Mail Address:
dd
mm
yyyy
dd
mm
yyyy
dd
mm
yyyy
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Yes
No
Yes
No