Auto Insurance Quote

Name:

Address:

Address:

Postal Code:


Phone Number:


Fax Number:


Email:

Year of Vehicle#1:


Make & Model:


Vehicle Model:


Model Style:


Name of Most Recent Insurance Comp.:


Year Continuously Insured:


Drivers License Master Number:


Policy Number (Optional):


Do you drive your car to and from work?
If yes how far away?
Yes No
Is your vehicle used for?
Business Pleasure Farming Fishing
(Check all that apply)
Annual Kilometers:

Drivers: 
Male/Female


Date of Birth:


Married/Single:


Any at fault claims in the last six years?


Any Glass/Comprehensive claims in the last six years?

Any lapses of insurance coverage?
(over 3 months in the last 6 years)

Any traffic violations in the last three years?


Have any of the drivers lost their drivers license over the past 6 years?

Coverage - Leave blank if not applicable
 
Liability Limit:
1 million 2 million

Collision Deductible:
250 500 1000

Collision Deductible:
100 250

Submitting this form does not bind the Proposer or the Insurer to complete the insurance but it is agreed that this Proposal and questionnaire shall be the basis of the insurance contract entered into the company.

I have read and understand the agreement
Yes