Auto Quote

Please fill out the form below if you would like an Automobile Insurance Quote. A representative from our office will contact you by the next business day.

 

Contact Information:  
Name:   
Address:   
City:   
Province:   
Postal Code:   
Phone Number:   
Email Address:   
How do you wish to be contacted:   
Have you ever had insurance cancelled or refused?:   
Yes No
Do you currently insure your car?:   
Yes No
If not, have you had insurance for 12 consecutive mths within the last 6yrs?:   
 Yes No
When should coverage start?:   
(dd/mm/yyyy)
Driver(s) Information :  
  Driver #1 Driver #2 Driver #3
Name:   
Driver's License #:   
Date first licensed in Canada:   
License Class:   
Sex:   
Marital Status:   
Driving Training:   
Yes No Yes No Yes No
Retired:   
Yes No Yes No Yes No
Minor traffic convictions in last 3 yrs:   
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc):   
 
       
Are you currently insured?:    Yes No
Name of previous insurance company:   
Have any of above drivers had their licenses suspended or lapsed in the past 6yrs:    Yes  No
Have any of the drivers above had accidents or claims in the past 10yrs:    YesNo
   
Claims Information:      
Claim #1: Driver Involved: Date (mm/yyyy):
     Description:  
Claim #2: Driver Involved: Date (mm/yyyy):
     Description:  
Claim #3: Driver Involved: Date (mm/yyyy):
     Description:  
   
Vehicle Information:  
Vehicle #1
Vehicle #2
 
Vehicle Make:  
 
Year:  
  
Model:  
  
Style:  
  
Use:  
  
KM Driven one way to work:  
 
KM driven per year:  
 
Who is the primary driver:  
 
Date Purchased:  
 
       
Coverage Required:
Vehicle #1
Vehicle #2
 
Liability:  
  
Collision deductible:  
 
Comprehensive deductible:  
 
Loss of Use (OPCF20):   
Yes No
Waiver of Depreciation (OPCF 43):   
Yes No
Claims Forgiveness (OPCF CPP):   
Yes No
       
Please copy the following text into the textbox below.
   
 
 

After Hours Claims Numbers

 
Aviva 1-800-590-5003 Economical 1-800-607-2424 Gore Mutual 1-800-265-8600
Guarantee 1-800-265-4262 Intact Insurance 1-866-464-2424 Jevco 1-514-919-8339
Kingsway 1-866-864-1112 Markel 1-888-627-5351 Nordic Facility 1-905-686-0200
Pafco 1-800-387-0462 Peel Mutual 1-800-268-3069 Western General 1-800-607-2424
Perth Insurance 1-800-607-2424 Pilot Insurance 1-888-887-4568    
           
 
 

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