Quote Requests - Partners Indemnity Insurance Brokers Ltd.

Car Insurance

Name:

Address:

City:

Province:

Postal Code:

Phone Number:

Email Address:

Have you ever had insurance cancelled or refused?

Yes

Do you currently insure your car?

Yes

If not, have you had insurance for 12 consecutive months within the last 6 years?

Yes

When should coverage start? (dd/mm/yyyy)

Driver(s) Information:

Name of Driver:

Date of Birth :

Drivers License #:

Years licensed in Canada:

License class:

Sex:

Marital status:

Driving school:

Retired?

Minor traffic convictions in the last 3 yrs:

Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):

Are you currently insured?

Yes

Name of previous insurance company:

Have any of above drivers had their licenses suspended or lapsed in the past 6 years?

Yes

Have any of the drivers above had accidents or claims in the past 10 years?

Yes

Claims Information:

Claims

Date (mm/yyyy)

Driver involved

#1:

#2:

#3:

Vehicle Information:

Vehicle #1

Vehicle #2

Vehicle make:

Year:

Model:

Style:

Use:

KM driven one way to work:

Kilometres driven per year:

Who is primary driver:

Coverage Required:

Vehicle #1

Vehicle #2

Liability:

Collision deductible:

Comprehensive deductible:

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