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Name
Email Address
Phone
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Year
Make
Model
Enter the distance you drive to work or school (one-way)
Enter 0 kilometers if you use your car for pleasure only
Yearly kilometers
Select…
0 to 2,000 km per year
2,001 to 4,000 km per year
4,001 to 6,000 km per year
6,001 to 8,000 km per year
8,001 to 10,000 km per year
10,001 to 13,000 km per year
13,001 to 16,000 km per year
16,001 to 20,000 km per year
20,001 to 24,000 km per year
24,001 to 30,000 km per year
30,001 or more km per year
Condition of the car when you got it
New
Used
Reading No of Km when bought
Purchase Price
CAD
Anti-theft system
You could save more if your car has an anti-theft system
None
TAG
Domino
Honda Plus Locate
Engraved parts after purchase
Other
Winter tires
Yes
No
Full Name
As it appears on your diver’s license
Gender identity
As it appears on your diver’s license
Male
Female
X
Date of birth
Age when you got your first driver's license in Canada or the U.S.
(including G1, G2, G)
Current driver's license class (G1, G2, G)
G1
G2
G
First insurance date (years)
Current insurance name
Number of years with current insurer
include the years you were covered by someone else’s policy
Any insurance lapses
If yes give details
Yes
No
Text
Any convictions
if yes give details
Yes
No
Text
Any previous claims
if yes give details
Yes
No
Text
Any suspensions/fraud/misrepresentations
if yes give details
Yes
No
Text
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