auto form service - Tanner Insurance Brokers

Who is your broker?*
Please select your broker. If you are unsure of who your broker is, select the person who sent you this form.

Registered Vehicle Owner
This will be the policy owner and must be the registered owner of the vehicle to be insured.
Registered Vehicle Owner's Name*
First Name Last Name
Phone Number*
Optional Secondary Phone Number
Email*
Optional Secondary Email
Address*
Address the vehicle will be registered to when your policy becomes effective. **Please include a unit # if there is one.**

Street Address City Province
Postal Code*
How did you hear about us?
Effective Date*
Requested Policy Start Date

Vehicle #1 Details
How many vehicles would you like quoted?*
Year of Vehicle*
Make & Model*
Be as specific as possible for most accurate quote.
VIN
Providing a VIN is not mandatory but will increase accuracy of the quote.
Condition When Bought*
What status was the vehicle when you purchased it?
Year Purchased?*
What year was the vehicle purchased?
How many KM's when purchased?*
Roughly how many KM's were on the vehicle when you purchased it?
Annual KM's Driven*
How many KM's do you expect to put on the vehicle over the course of the next year?
Daily Commute KM's Driven*
Distance one-way from home to work.
Annual Business KM's Driven*
This includes ride sharing or food delivery.
Winter tires?*
What type of tire do you use in the winter?
Is vehicle currently financed or leased?*
Coverage Required:*
If financed or leased full coverage is mandatory.
Any Pre-Existing Damage on the Vehicle?
If any pre-existing damage please be as detailed as possible explaining the damage.
- No Damage

Vehicle #2 Details
Year of Vehicle*
Make & Model*
Be as specific as possible for most accurate quote.
VIN
Providing a VIN is not mandatory but will increase accuracy of the quote.
Condition When Bought*
What status was the vehicle when you purchased it?
Year Purchased?*
What year was the vehicle purchased?
How many KM's when purchased?*
Roughly how many KM's were on the vehicle when you purchased it?
Annual KM's Driven*
How many KM's do you expect to put on the vehicle over the course of the next year?
Daily Commute KM's Driven*
Distance one-way from home to work.
Annual Business KM's Driven*
This includes ride sharing or food delivery.
Winter tires?*
What type of tire do you use in the winter?
Is vehicle currently financed or leased?*
Coverage Required:*
If financed or leased full coverage is mandatory.
Any Pre-Existing Damage on the Vehicle?
If any pre-existing damage please be as detailed as possible explaining the damage.
- No Damage

Vehicle #3 Details
Year of Vehicle*
Make & Model*
Be as specific as possible for most accurate quote.
VIN
Providing a VIN is not mandatory but will increase accuracy of the quote.
Condition When Bought*
What status was the vehicle when you purchased it?
Year Purchased?*
What year was the vehicle purchased?
How many KM's when purchased?*
Roughly how many KM's were on the vehicle when you purchased it?
Annual KM's Driven*
How many KM's do you expect to put on the vehicle over the course of the next year?
Daily Commute KM's Driven*
Distance one-way from home to work.
Annual Business KM's Driven*
This includes ride sharing or food delivery.
Winter tires?*
What type of tire do you use in the winter?
Is vehicle currently financed or leased?*
Coverage Required:*
If financed or leased full coverage is mandatory.
Any Pre-Existing Damage on the Vehicle?
If any pre-existing damage please be as detailed as possible explaining the damage.
- No Damage

Vehicle #4 Details
Year of Vehicle*
Make & Model*
Be as specific as possible for most accurate quote.
VIN
Providing a VIN is not mandatory but will increase accuracy of the quote.
Condition When Bought*
What status was the vehicle when you purchased it?
Year Purchased?*
What year was the vehicle purchased?
How many KM's when purchased?*
Roughly how many KM's were on the vehicle when you purchased it?
Annual KM's Driven*
How many KM's do you expect to put on the vehicle over the course of the next year?
Daily Commute KM's Driven*
Distance one-way from home to work.
Annual Business KM's Driven*
This includes ride sharing or food delivery.
Winter tires?*
What type of tire do you use in the winter?
Is vehicle currently financed or leased?*
Coverage Required:*
If financed or leased full coverage is mandatory.
Any Pre-Existing Damage on the Vehicle?
If any pre-existing damage please be as detailed as possible explaining the damage.
- No Damage

Driver #1 Details
How many drivers would you like to include?*
Driver # 1 Name*
First Name Last Name
Gender*
Driver # 1 Date of Birth*
Driver # 1 Marital Status*
Driver # 1 Occupation:
Certain occupations qualify for preferred rates, be as detailed as possible.
Driver # 1 Current License Held*
Driver # 1 Driver Training*
If you successfully completed driver training in Ontario and can provide a certificate you will receive a discount.
Driver # 1 Ontario Driver's License Number*
How many tickets in past 3 years?*
Parking tickets don't count.
How many accidents in past 6 years?*
How many drivers license suspensions in past 3 years?*
How many cancellations by the insurance company in past 3 years for non-payment?*

Driver #2 Details
Driver # 2 Name*
First Name Last Name
Gender*
Driver # 2 Date of Birth*
Driver # 2 Marital Status*
Driver # 2 Occupation:
Certain occupations qualify for preferred rates, be as detailed as possible.
Driver # 2 Current License Held*
Driver # 2 Driver Training*
If you successfully completed driver training in Ontario and can provide a certificate you will receive a discount.
Driver # 2 Ontario Driver's License Number*
How many tickets in past 3 years?*
Parking tickets don't count.
How many accidents in past 6 years?*
How many drivers license suspensions in past 3 years?*
How many cancellations by the insurance company in past 3 years for non-payment?*

Driver #3 Details
Driver # 3 Name*
First Name Last Name
Gender*
Driver # 3 Date of Birth*
Driver # 3 Marital Status*
Driver # 3 Occupation:
Certain occupations qualify for preferred rates, be as detailed as possible.
Driver # 3 Current License Held*
Driver # 3 Driver Training*
If you successfully completed driver training in Ontario and can provide a certificate you will receive a discount.
Driver # 3 Ontario Driver's License Number*
How many tickets in past 3 years?*
Parking tickets don't count.
How many accidents in past 6 years?*
How many drivers license suspensions in past 3 years?*
How many cancellations by the insurance company in past 3 years for non-payment?*

Driver #4 Details
Driver # 4 Name*
First Name Last Name
Gender*
Driver # 4 Date of Birth*
Driver # 4 Marital Status*
Driver # 4 Occupation:
Certain occupations qualify for preferred rates, be as detailed as possible.
Driver # 4 Current License Held*
Driver # 4 Driver Training*
If you successfully completed driver training in Ontario and can provide a certificate you will receive a discount.
Driver # 4 Ontario Driver's License Number*
How many tickets in past 3 years?*
Parking tickets don't count.
How many accidents in past 6 years?*
How many drivers license suspensions in past 3 years?*
How many cancellations by the insurance company in past 3 years for non-payment?*

Driver #5 Details
Driver # 5 Name*
First Name Last Name
Gender*
Driver # 5 Date of Birth*
Driver # 5 Marital Status*
Driver # 5 Occupation:
Certain occupations qualify for preferred rates, be as detailed as possible.
Driver # 5 Current License Held*
Driver # 5 Driver Training*
If you successfully completed driver training in Ontario and can provide a certificate you will receive a discount.
Driver # 5 Ontario Driver's License Number*
How many tickets in past 3 years?*
Parking tickets don't count.
How many accidents in past 6 years?*
How many drivers license suspensions in past 3 years?*
How many cancellations by the insurance company in past 3 years for non-payment?*

Consent*
By providing your driver's license number, you are hereby authorizing us to retrieve your prior insurance information, including those of any previously listed drivers from whom I have obtained consent, in order to provide you with a faster, more accurate quote. Do I have permission to retrieve your insurance information?
I agree to grant permission to retrieve up to 25 years of my insurance information
Upload / Comments
Optional Picture & Document Upload
Optional feature, upload picture of vehicle, ownership, driver's license, if you are coming from out of province you can attach a "Claim's Letter of Experience" from your former insurer too.
Drop files here or

Max. file size: 50 MB.
Optional Comments
Include any additional comments.

Registered Vehicle Owner

Vehicle #1 Details

Vehicle #2 Details

Vehicle #3 Details

Vehicle #4 Details

Driver #1 Details

Driver #2 Details

Driver #3 Details

Driver #4 Details

Driver #5 Details

Upload / Comments

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