Information for Auto Insurance Quotation

What Broker are you working with?(Required)

Referred by:(Required)

Name:(Required)

First Last

Address:(Required)

Street Address Address Line 2 City Province Postal Code

Email:(Required)

Phone:(Required)

Preferred Method of Contact:(Required)

Phone

Do you currently have Auto Insurance?(Required)

Yes

Current Auto Insurance Company:(Required)

Renewal Date:(Required)

MM slash DD slash YYYY

Do you currently have Home Insurance?(Required)

Yes

Current Home Insurance Company:(Required)

Renewal Date:(Required)

MM slash DD slash YYYY

Drivers & Vehicles

How many drivers are there in the household?(Required)

How many vehicles are there in the household?(Required)

Principle Operator (Driver #1)

Name (Principle Operator - Driver #1):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #2

Name (Driver #2):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously insured since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #3

Name (Driver #3):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #4

Name (Driver #4):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insurance Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #5

Name (Driver #5):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #6

Name (Driver #6):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Vehicle Information (Vehicle #1)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add more drivers.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #1)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Coverage for Rented or Borrowed Vehicles(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #2)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #2)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Coverage for Rented or Borrowed Vehicles(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #3)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #3)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Coverage for Rented or Borrowed Vehicles(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #4)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #4)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Coverage for Rented or Borrowed Vehicles(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #5)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #5)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Coverage for Rented or Borrowed Vehicles(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #6)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #6)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Coverage for Rented or Borrowed Vehicles(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Privacy

Consent(Required)

I agree to the privacy policy.

As part of my application for insurance, I hereby consent to the brokerage firm named below (the
“Broker”) collecting, using, and disclosing my personal information, including my insurance and claims history, for purposes of obtaining quotes for me for new or renewal personal lines insurance,
property/casualty and/or automobile insurance, as applicable, and to provide such personal information to third parties for this purpose, including to disclose this information to insurance companies and third-party insurance rating service providers for the purposes of their assessing risk, determining my eligibility for insurance coverage and setting premiums (“Underwriting Purposes”). I understand that information will be collected directly from me and from third parties such as credit bureaus, the Ministry of Transportation, other insurers, and insurance rating service providers.

I understand that, for automobile insurance Underwriting Purposes, some insurers may require up to 25 years of personal information such as driving record and claims history about me and all other permitted drivers and agree to provide the requested information. I represent and warrant that I have obtained consent from the other permitted drivers to also grant this permission in relation to their personal information.

I understand that the Broker may be required or permitted to disclose my personal information without my consent pursuant to relevant privacy laws or other laws. The Broker will otherwise handle my personal information in accordance with its privacy policy, which is available on request. If I wish to review personal information pertaining to my application or policy maintained by the Broker, obtain copies of the Broker’s privacy policies or standards, or make other enquiries or express concerns, I understand that I may do so by contacting the Broker’s Privacy Officer. I understand I can access further guidelines on Broker Conduct and the Fair Treatment of Customers online or by request.

I understand that I may withdraw consent at any time on reasonable notice and that if I do so, the Broker may not be able to provide me with the requested quote(s).

Additional Notes or Information

Phone

This field is for validation purposes and should be left unchanged.

Important Notice

Information for Auto Insurance Quotation