Name:
Address:
City:
Postal Code:
Phone:
Fax:
EMail:

Date Of Birth:
# of yrs driving in Canada:
# of years continously insured:
Use of Vehicle:	Pleasure Business
If driven to work, # of km one way:

Current Insurance Company Name:
Expiry Date:

DRIVER HISTORY

Any 'At Fault' claims in last 6 years?:	Yes No
If yes, give brief details:
Any convictions (speeding tickets etc.) in the last 3 years?:	Yes No
If yes, give details (i.e. 10 Km over limit):

AUTOMOBILES

Veh #1: Year, Make and Model:
Veh #2: Year, Make and Model:

COVERAGE SELECTOR

Liability:	$1 Million $2 Million $5 Million
Accident Benefits:	Standard - Included
Collision Deductible::	$300 $500 $1000
Comprehensive Deductible:	$300 $500 $1000
Loss of Use Endorsement: (pays for a rental car if yours is damaged)	Yes No
Rental Car Coverage: (provides coverage for frequent car renters)	Yes No
Waiver of Depreciation: (for cars less than 3 yrs old)	Yes No
How would you prefer to be contacted:	Phone Fax Email Regular Mail