UXBRIDGE
33 Toronto St. N.
Box #1540
Uxbridge, ON L9P 1N7
905-852-9191 or
1-888-354-6444
Fax: 905-852-6088

MOUNT ALBERT
19139 Centre Street
Box 130
Mount Albert, ON L0G1M0
905-473-2797 or
1-888-301-5222
Fax: 905-473-5499

Automobile Insurance Quote

Should you not wish to complete the following form, please provide a day time phone number so that we may contact you by phone.

Contact Information:
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
How do you wish to be contacted:

Have you ever had insurance cancelled or refused?:	Yes No
Do you currently insure your car?:	Yes No
If not, have you had insurance for 12 consecutive mths within the last 6yrs	Yes No
When should coverage start? :	(dd/mm/yyyy)

Driver(s) Information :
	Driver #1	Driver #2	Driver #3
Name:
Driver's License # :
Years licensed in Canada :
License Class:
Sex:
Marital Status:
Driving Training :	Yes No	Yes No	Yes No
Retired:	Yes No	Yes No	Yes No
Minor traffic convictions in last 3 yrs :
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc):


Are you currently insured?:	Yes No
Name of previous insurance company :
Have any of above drivers had their licenses suspended or lapsed in the past 6 years :	Yes No
Have any of the drivers above had accidents or claims in the past 10 yrs :	Yes No


Claims Information:	Claims
Claim #1:	Driver Involved:
	Date (mm/yyyy):
	Description:
Claim #2:	Driver Involved:
	Date (mm/yyyy):
	Description:
Claim #3:	Driver Involved:
	Date (mm/yyyy):
	Description:


Vehicle Information:	Vehicle #1	Vehicle #2
Vehicle Make:
Year:
Model:
Style:
Use:
KM Driven one way to work:
KM driven per year:
Who is the primary driver:
Date Purchased:


Coverage Required:	Vehicle #1	Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:


Please copy the following text into the textbox below.