Vehicle Addition

Disclaimer: Coverage is not considered bound or in effect until you have received confirmation from a licensed broker.

(required)

(required)

(required)

Address 1 (Required - Street Number and Name)

Address 2 (Optional - Unit, Floor, etc.)

City (required)

Province (required)

Postal Code (required)

(required)



EmailPhone

Vehicle Details

(required, YYYY)

(required)

(required)

(required)

(required)

(required)

Month

Day

Year (YYYY)


Work CommutePleasure UseBusiness Use

How many KM’s one way to work

how many KM’s annually

% of business KM’s


$500,000$1,000,000$2,000,000Other


$250$500$1000Decline


$100$250$500$1000Decline


$250$500$1000Decline

(check all that apply)
SEF 5SEF 20SEF 27SEF 39SEF 43


Same as ContactDifferent Contact

Full Name


Same as ContactDifferent Address

Address 1 (Required - Street Number and Name)

Address 2 (Optional - Unit, Floor, etc.)

City (required)

Province (required)

Postal Code (required)