your info

your name:

city:

postal code:

phone number:

email address:

driver information

number of drivers:

driver #1 - date of birth (mm/dd/yyyy):

driver #2 - date of birth (mm/dd/yyyy):

driver #3 - date of birth (mm/dd/yyyy):

driver #4 - date of birth (mm/dd/yyyy):

driver #5 - date of birth (mm/dd/yyyy):

license date of issue

driver #1 (mm/dd/yyyy)- g1: g2: g:

driver #2 (mm/dd/yyyy)- g1: g2: g:

driver #3 (mm/dd/yyyy)- g1: g2: g:

driver #4 (mm/dd/yyyy)- g1: g2: g:

driver #5 (mm/dd/yyyy)- g1: g2: g:

did you attain the drivers' training certificate

driver 1: yes no

driver 2: yes no

driver 3: yes no

driver 4: yes no

driver 5: yes no

vehicle information

auto #1 - model: make: year: number of doors:

auto #2 - model: make: year: number of doors:

auto #3 - model: make: year: number of doors:

auto #4 - model: make: year: number of doors:

auto #5 - model: make: year: number of doors:

name of present insurer: renewal date (mm/dd/yyyy):

accident or claims in the last 6 years

please indicate if there have been any accident or claims in the last 6 years. this pertains to at-fault or not-at-fault accidents or any type of claims.

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

driver # date (mm/dd/yyyy): at fault: yes no - amount paid: $

motor vehicle infractions

please indicate if there have been any motor vehicle violation infractions in the last 3 years. do not put any parking tickets. if you indicate speeding then please indicate how many km over the speed limit in the km over field.

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

suspension of license

has any driver in the household had a suspension of license in the past 6 years?

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

driver # date (mm/dd/yyyy): - violation - km over:

insurance cancellations

has any insurance company cancelled, declined, or non-renewed any insurance policy to the application or any of the listed drivers in the past 3 years? this would include policy cancelled by the insurance company for non-payment of premium.

driver # date (mm/dd/yyyy): - reason

driver # date (mm/dd/yyyy): - reason

driver # date (mm/dd/yyyy): - reason

driver # date (mm/dd/yyyy): - reason

driver # date (mm/dd/yyyy): - reason

coverages for auto 1

liability:

collision deductable:

comprehensive:

coverages for auto 2

liability:

collision deductable:

comprehensive:

coverages for auto 3

liability:

collision deductable:

comprehensive:

coverages for auto 4

liability:

collision deductable:

comprehensive:

coverages for auto 5

liability:

collision deductable:

comprehensive:

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