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Name Telephone Postal Code Vehicle # 1 Year Make Model Use of Vehicle # km to work # km/year Collision Deductible Liability Amount Comprehensive  Deductible Pleasure Business Both 250 500 None 200,000 500,000 1,000,000 2,000,000 100 250 500 None Vehicle #2 V e h ic l e #     2 Year Make Model Use of Vehicle # km to work # km/year Collision Deductible Liability Amount Comprehensive  Deductible Pleasure Business Both 250 500 None 200,000 500,000 1,000,000 2,000,000 100 250 500 None To insure more than 3  vehicles, please contact one of our sales representatives Driver #1 Name Date of Birth Gender Marital  Status Male Female Married Single Drivers Licence  Number License  Class # Years  Licenced Driver Training Yes No # uninterrupted years  insurance Renewal  date # claims (not accidents) in the past 6 years # accidents in the past 6 years Yes No Have you ever had your insurance cancelled? Yes No Any convictions in the past 3  years? Yes No Has your drivers licence ever been suspended? Driver #2 Name Date of Birth Gender Marital  Status Male Female Married Single Drivers Licence  Number License  Class # Years  Licenced Driver Training Yes No # of uniterrupted years  insurance Renewal  date # claims (not accidents) in the past 6 years # accidents in the past 6 years Yes No Have you ever had your insurance cancelled? Any convictions in the past 3  years? Yes No Yes No Has your drivers licence ever been suspended? If more than 2 drivers live in your house, please contact one of our representatives for a  quote Thank you for taking the time to fill out  our online quote form.  One of our representative will contact you soon.

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