Auto Quote Form PS

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 is registered to.

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?*
Only automobiles, we have a separate form for motorcycles, ATV's, snowmobiles.
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*
Winter tires?*
What type of tire do you use in the winter?
Does the vehicle have an anti-theft device installed?*
What anti-theft device does the vehicle have installed?
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
Is The Vehicle Modified/Customized?*
Please Specify Modifications:*

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*
Winter tires?*
What type of tire do you use in the winter?
Does the vehicle have an anti-theft device installed?*
What anti-theft device does the vehicle have installed?
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
Is The Vehicle Modified/Customized?*
Please Specify Modifications:*

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*
Winter tires?*
What type of tire do you use in the winter?
Does the vehicle have an anti-theft device installed?*
What anti-theft device does the vehicle have installed?
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
Is The Vehicle Modified/Customized?*
Please Specify Modifications:*

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*
Winter tires?*
What type of tire do you use in the winter?
Does the vehicle have an anti-theft device installed?*
What anti-theft device does the vehicle have installed?
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
Is The Vehicle Modified/Customized?*
Please Specify Modifications:*

Driver #1 Details
Including yourself how many licensed drivers in the household?*
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
Accident Benefit Changes in Ontario*
As of July 1, 2026, Ontario is introducing changes under the Insurance Act (Ontario) that will provide Ontario drivers with more choice and control over their Statutory Accident Benefits coverage. Under the new rules, only medical, rehabilitation, and attendant care benefits will remain mandatory, while many other important coverages such as, income replacement, caregiver benefits, and death and funeral benefits will become optional and must be selected by the policyholder.
We encourage you to review the resources provided upon completion of this form.
I acknowledge that I've read the Accident Benefits Changes in Ontario.
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Picture & Document Upload
Optional feature, upload picture of vehicle, ownership, driver's license, etc.
Drop files here or

Max. file size: 50 MB.
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