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Auto Insurance
PERSONAL INFORMATION
Name:
Effective Date:
Calendar
Birthdate:
Calendar
Phone 1:
Phone 2:
Email:
Current Address:
City:
Province:
Postal:
Driver License:
G License Date:
Calendar
G1 License Date:
Calendar
G2 License Date:
Calendar
Occupation:
Accidents:
Convictions:
Annual KM:
KM driven to work:
Previous Insurance Company:
Previous Policy #:
Years with previous insurer:
Total years of Insurance experience:
SPOUSE
Name:
Birthdate:
Calendar
Phone 1:
Phone 2:
E-mail:
Drivers License #:
G License Date:
Calendar
G1 License Date:
Calendar
G2 License Date:
Calendar
Occupation:
Accidents (date & description):
Convictions (date and type):
VEHICLE
Year:
Calendar
Make:
Model:
VIN#:
Purchase Date:
Calendar
New or Used:
New
Used
Ownership:
Fuel type:
Gas
Diesel
Electric
Hybrid
Snow Tires:
Yes
No
Use (pleasure or business):
Pleasure
Business
Occasional Business
Principle Driver:
Storage Location:
Driveway
Garage
Carport
Street
Underground
Parking Lot
COVERAGE
Liability Limit:
$2,000,000
$1,000,000
Comprehensive Deductible:
N/A
$0
$300
$500
$1000
$2500
Other
Collision Deductible:
N/A
$300
$500
$1000
$2500
Other
(or) All Perils Deductible:
N/A
$0
$500
$1000
$2500
Other
OPCF44:
Yes
No
OPCF20:
Yes
No
OPCF27:
Yes
No
OPCF35:
Yes
No
OPCF43:
N/A
Yes
No
OPCF13:
Yes
No
AFE:
Yes
No
N/A
ADDITIONAL DRIVERS
Name:
Driver's License #:
COMMENTS
Additional Comments: