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?*
If you were referred to Connor, Perry or Melanie please let us know.
Effective Date*
Requested Policy Start Date
MM slash DD slash YYYY

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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?
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

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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?
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

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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?
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

Save and Continue Later

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?
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

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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*
MM slash DD slash YYYY
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?*

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Driver #2 Details
Driver # 2 Name*
First Name Last Name
Gender*
Driver # 2 Date of Birth*
MM slash DD slash YYYY
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?*

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Driver #3 Details
Driver # 3 Name*
First Name Last Name
Gender*
Driver # 3 Date of Birth*
MM slash DD slash YYYY
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?*

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Driver #4 Details
Driver # 4 Name*
First Name Last Name
Gender*
Driver # 4 Date of Birth*
MM slash DD slash YYYY
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?*

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Driver #5 Details
Driver # 5 Name*
First Name Last Name
Gender*
Driver # 5 Date of Birth*
MM slash DD slash YYYY
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?*

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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 my insurance information
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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.

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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