Auto Insurance

Name:

Address:

City:

Province:

Postal Code (X1Y 2Z3):

Phone Number (123-456-7890):

Email Address:

What is your date of birth?:

Marital status of principal driver:

Number of years licensed for principal driver:

Gender of additional drivers under 25 years of age:

Do driver(s) under 25 years of age have driver training certification:

Yes

Any driving convictions in past 3 years:

Yes

If so (# of convictions):

Do you use your vehicle for business:

Yes

Do you use your vehicle to commute to and from work:

Yes

Year, make, and model of vehicle:

Liability limit requested:

Coverage Preferred:

Deductible:

Additional vehicles to be quotes:

Yes

Require any increase accident Benefits:

Yes

How many years have you consistently had an auto policy in force or been listed on someone else’s policy as a listed driver:

Number of at fault claims in the past 10 years:

How many years since last at fault claim (if within 10 years):

Date of Last Claim (if within 10 years):

How many kilometers do you commute to work 1 way:

Was your prior policy canceled for non payment:

Yes

Was your policy lapsed for any other reason by the insurance company:

Which insurance company has your current property insurance:

Your Protection is Our Business

Atrens-Counsel Insurance Brokers, a division of Arthur J. Gallagher Canada Limited.

Name:

Location Address:

Mailing Address (if different than location address):

Daytime Phone Number:

Email:

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*Coverage will not be bound until spoken with a license insurance broker