To get a no-obligation quote on your auto insurance, please complete the following form and submit it to our office. We will contact you within the next two business days. Please note: we can only provide insurance for residents of Alberta, Canada.
Tell us about yourself...
Please Note: It is imperative that all fields be completed for us to give you an accurate quote.
Last name:
First name:
Address:
City:
Province:
Postal Code:
Phone:
E-mail:
Have you ever had your insurance cancelled or refused?
Yes No
Do you own your own home or condominium?
Are you retired?
Do you use your vehicle for business purposes?
If yes, what type of work do you do?
How often do you use your car for business?
How far do you drive, one way to work?
When would you want the coverage to start?
dd
mm
yyyy
Do you currently have insurance through another company?
If yes, what is the name of the insurance company?
What is your insurance policy #?
If no, have you had insurance for 12 consecutive months within the past 6 years?
If yes, what was the name of the insurance company?
What was your insurance policy #?
Have you had continuous insurance with the same carrier for the past 3 years?
If no, please explain:
Have you had continuous automobile insurance for the past 5 years?
How did you hear about us?
Tell us about the drivers...
Driver 1
Driver 2
Driver 3
Name:
Age:
yrs old
Years licensed in Canada:
years
Driver's License #:
License Class:
G G1 G2
When did you get the following class of license:
G1 (mm/yyyy)
G2
G
Sex:
Male Female
Marital status:
Married Single Common-law
Driving school?
Minor traffic convictions in the past 3 years:
None One Two Three Over Three
** minor violations include speeding, seatbelt, prohibited turn and other similar offenses **
Major traffic convictions in the past 3 years:
** major violations include impaired driving, careless driving, refusing breathalyzer & other similar offenses**
Have any of the listed drivers ever had their insurance cancelled or refused in the past 3 years?
If yes, please explain:
Do any of the listed drivers have driving experience outside Canada or the United States?
If yes, please provide details:
Have any of the listed drivers had their licence suspended or revoked in the past 3 years?
In the past 6 years, have any of the above drivers been involved in a car accident, or have any claims been made to your insurance company?
Yes No If yes, please complete Claims Information
Claims Information
Type of Claim:
Date of Claim mm yyyy
Driver Involved:
1.
None At-fault Accident Not-at-fault Accident Partial At-fault Accident Windshield/Vandalism/Theft
None Driver 1 Driver 2 Driver 3 Other Driver
2.
3.
Tell us about the vehicles...
Vehicle 1
Vehicle 2
Year:
Make:
Model:
Style:
2 Door 2 Door Hatch 4 Door 4 Door Hatch Station Wgn Sport Utility Pick-up Van
Use:
Pleasure Only Commute < 5 km Commute 6-15 km Commute 16-25 km Commute 26+ km Partial Business Business
How many Km do you drive per year:
< 5,000 km < 10,000 km < 15,000 km < 20,000 km < 25,000 km > 25,000 km
Who is Primary Driver:
Driver 1 Driver 2 Driver 3
Coverages & Deductibles
Liability:
$200,000 $500,000 $1,000,000 $2,000,000
deductible
Collision:
$300 $500 $1,000
Comprehensive:
$100 $300 $500 $1,000
Remarks
Your Privacy You are authorizing that we collect, use or disclose your personal information contained on this information form as well as any additional information that we may obtain about you and other listed beneficiaries based on the information you have disclosed to us, (for example confirming your claims history or checking with motor vehicle agencies), for the purpose of providing you with this quote. By submitting this information form you also confirm that you have obtained the permission of all other potential beneficiaries listed on this information form for the collection, use and disclosure of their Personal Information for the purpose of providing you with this quote. Submission of this form does not constitute an application for insurance. Do you consent? Yes No
Thank you for taking the time to fill out this form. Select the "Submit" button below and we will contact you within the next two business days. Our quote will include the coverages you selected plus the standard Accident Benefits coverages. We will include the cost of popular optional coverages with our quotation. Optional Accident Benefit coverages can be upgraded by consulting one of our brokers.
* Coverage is subject to the insurer's underwriting policies.
** To learn more about the protection of your personal information, consult Privacy & Legal.
