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PERSONAL INFORMATION
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| *First Name |
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| *Last Name |
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| Address |
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| City |
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| Province |
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| *Postal Code |
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| *Home Telephone (with area code) |
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| Work Telephone (with area code) |
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| Fax |
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| E-mail |
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| Occupation |
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INSURANCE POLICY INFORMATION
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| *Are you currently insured? |
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| If yes, what is the name of your current insurance company? |
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| *When does your current policy expire? (If you are not currently insured, please provide the date you would like coverage to begin.) |
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| How long have you had continuous insurance (without interruption)? |
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| Has your insurance policy ever been cancelled by an insurance company in the past 3 years? |
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| Has the insurance policy of any listed driver been cancelled by an insurance company in the past 3 years? |
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| If you are not currently insured, but have had insurance in the last 10 years, when was the last time you were insured? |
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DRIVER INFORMATION
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| How many licensed drivers in the household?
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Driver 1 |
| *Driver's Name |
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| *Date of Birth |
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| Marital Status |
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| Gender |
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| License Class |
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| Years Fully Licensed |
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| *Did you complete an approved driver training course in the last 6 years? |
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| How many driving infractions have you had in the last 3 years? |
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| *How many not-at-fault accidents/claims have you had in the last 6 years? (including comprehensive i.e. windshield, theft, etc.) |
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| *How many years since your last not-at-fault accident? |
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| *How many at-fault accidents have you had in the last 10 years? |
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| *How many years since your last at-fault accident? |
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| *Has your licence been suspended in the last 3 years? |
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Driver 2 |
| *Driver's Name |
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| *Date of Birth |
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| Marital Status |
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| Gender |
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| License Class |
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| Years Fully Licensed |
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| *Did you complete an approved driver training course in the last 6 years? |
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| How many driving infractions have you had in the last 3 years? |
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| *How many not-at-fault accidents/claims have you had in the last 6 years? (including comprehensive i.e. windshield, theft, etc.) |
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| *How many years since your last not-at-fault accident? |
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| *How many at-fault accidents have you had in the last 10 years? |
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| *How many years since your last at-fault accident? |
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| *Has your licence been suspended in the last 3 years? |
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Driver 3 |
| *Driver's Name |
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| *Date of Birth |
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| Marital Status |
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| Gender |
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| License Class |
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| Years Fully Licensed |
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| *Did you complete an approved driver training course in the last 6 years? |
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| How many driving infractions have you had in the last 3 years? |
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| *How many not-at-fault accidents/claims have you had in the last 6 years? (including comprehensive i.e. windshield, theft, etc.) |
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| *How many years since your last not-at-fault accident? |
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| *How many at-fault accidents have you had in the last 10 years? |
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| *How many years since your last at-fault accident? |
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| *Has your licence been suspended in the last 3 years? |
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VEHICLE INFORMATION
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| Total number of vehicles in the household?
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Vehicle 1 |
| *Year (example: 1986) |
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| *Make (example: Ford) |
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| *Model (example: Taurus GL) |
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| Body Type |
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| Vehicle ID Number |
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| *Is this vehicle leased? |
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| *Who is the registered owner/lessee of this vehicle? |
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| *Who is the principle driver? |
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| Are there any occasional drivers? |
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Year licensed |
| How do you use your vehicle |
| *Primary vehicle use |
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| *Approx. km driven per year? |
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| Approx. km driven to work (one way)? |
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| Approx. business km driven per year? |
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| Standard Coverages |
| *Comprehensive Deductible |
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| *Collision Deductible |
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| *All Perils Deductible (combines collision and comprehensive) |
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| *Liability |
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| Included Coverages |
| Direct compensation - property damage |
Included |
| Accident benefits |
Included |
| Uninsured motorist |
Included |
| No. 44 - Family protection |
Included |
| Optional Coverages |
| No. 20 - Transportation replacement |
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| No. 27 - Legal liability for damage to non-owned automobiles |
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| No. 43 - Limited waiver of depreciation |
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| Roadside Assistance |
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| Any optional benefits required? |
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| What type of theft protection device does your vehicle have? |
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Vehicle 2 |
| *Year (example: 1986) |
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| *Make (example: Ford) |
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| *Model (example: Taurus GL) |
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| Body Type |
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| Vehicle ID Number |
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| *Is this vehicle leased? |
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| *Who is the registered owner/lessee of this vehicle? |
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| *Who is the principle driver? |
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| Are there any occasional drivers? |
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Year licensed |
| How do you use your vehicle |
| *Primary vehicle use |
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| *Approx. km driven per year? |
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| Approx. km driven to work (one way)? |
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| Approx. business km driven per year? |
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| Standard Coverages |
| *Comprehensive Deductible |
|
| *Collision Deductible |
|
| *All Perils Deductible (combines collision and comprehensive) |
|
| *Liability |
|
| Included Coverages |
| Direct compensation - property damage |
Included |
| Accident benefits |
Included |
| Uninsured motorist |
Included |
| No. 44 - Family protection |
Included |
| Optional Coverages |
| No. 20 - Transportation replacement |
|
| No. 27 - Legal liability for damage to non-owned automobiles |
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| No. 43 - Limited waiver of depreciation |
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| Roadside Assistance |
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| Any optional benefits required? |
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| What type of theft protection device does your vehicle have? |
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Every effort is made to provide an accurate estimate, and is based on the information that has been entered however should additional details be required, the estimate may change.
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11 Lloyd Street, Saint John, NB E2M 4N4