Name: Name
Address:Address

Address:Address

Postal Code:
Postal Code

Phone Number:
Phone #

Fax Number:
Fax #

Email:Email

Year of Vehicle#1:
Year of Vehicle #1

Make & Model:
Make and Model

Vehicle Model:


Model Style:


Name of Most Recent Insurance Comp.:


Year Continuously Insured:
Year Continuously Insured

Drivers License Master Number:
Drivers License Master Number

Policy Number (Optional):
Policy Number

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:
Annual Kilometers

Drivers:

 
Male/Female


Date of Birth:
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