Auto Insurance Applicaton

Please fill out the following information below

Contact Informaton --------------------------------------------------------------------------------

Name:

Address:

City:

Province:

Postal Code:

Email Address:

Home Phone:                   (                    )

Cell Phone:                       (                    )

Fax Phone:                        (                    )

Preferred method of contact:

Insurance Informaton ------------------------------------------------------------------------------------------------------------

How many claims in the past 3 years?:

Please give us your vehicle details:

Vehicle Make:

Vehicle Year:

Vehicle Type:

Vehicle Plate #:

Date of birth:

Driver's License #:

Has your driver's licence been suspended during
the last 5 years?:

How many traffic convictions have you had within
the last 3 years?

What is your vehicle used for?:

Please describe the commercial / business use of this vehicle: