Home Quote Tenant Quote Life Quote Get a Quote NowAuto Insurance Quote RequestGet a Quote - Auto Years continuously licensed & insured in Canada? * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+ Have you ever had any cancellations, accidents, tickets, or gaps in insurance in the last 6 years? * Yes No First Name * Last Name * Email * Address * Address Address Address City City Province Province Postal Code Postal Code Phone * Effective Date * Do you own a home or rent? * Own a Home Rent N/AAs your broker, I am gathering this consent on behalf of the insurer who advises me that: in respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may collect,use and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law and in accordance with our privacy policies.Do you, and on behalf of others listed, authorize use to collect, use and disclose to appropriate third parties, including your broker, this information solely relating to your personal property policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settile claims, analyze business results and detect and prevent fraud?Do you agree with the following consent statement? * Yes NoVehicle Information Year * Make * Model * CoveragesHow did you purchase your vehicle? * New UsedIs the vehicle leased or financed? * Leased Financed N/ALiability * 1 million 2 millionLoss / Damage * Collision Comprehensive None of the aboveDistance Driven How many kilometres driven to work/school one way? * 0 5 10 15 20 25 30+ Annual kilometres * Less than 10,000 15,000 20,000 25,000 30,000 Over 30,000 Business Use * Yes NoClick 'Add' if you like to add another vehicle. Add RemoveDriver Sex * Male Female Prefer Not To SayPrefer Not To Say Name * Birth Date * Occupation * Date License Obtained * Date First Insured In Canada * Current Insurance Company * Allstate Aviva CAA Echelon Economical ICPEI Intact Pembridge Portage Mutual RSA TD Wawanesa Other Current Insurance Company Number of At-Fault Accidents in Last 6 Years * 0 1 2 3 4 5 Number of Minor Convictions in Last 3 Years * 0 1 2 3 4 5 Number of Major Convictions in Last 5 Years * 0 1 2 3 4 5 Are there any other licensed drivers living in your household? * Yes No Relationship * Click 'Add' if you like to add another driver. Add RemoveAdditional InformationAre you interested in any of the following insurance products? * Home Insurance Condo Insurance Tenant Insurance Life Insurance OtherOther Any additional information? The information on this application is true and correct to the best of my knowledge. I authorize the person to whom this application is delivered to perform a soft credit check. I understand that a soft credit check is a non-intrusive test that does not affect my credit score and will not increase my insurance premium, only add additional savings. This information will be used strictly for the purposes of verifying information and will be held in confidence.Do you agree with the following consent statement? * Yes No Submit If you are human, leave this field blank.
