Driver information: Please enter the information for the driver who will be the policyholder first.
This is usually the owner or lessee of the vehicle.   NOTE: USE TAB TO FOLLOW FIELD SEQUENCE

Name
Street Address
Address (cont.)
City	Province
Postal Code	Country
Work Phone	Home Phone
E-mail	URL
Date of Birth  Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Year 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908	Sex    Male Female
How many Drivers per vehicle? 1 2 3 4 More than 4	How many Vehicles on this Quote? 1 2 3 4 More than 4 *
Marital status Please choose Single Widowed Divorced Common-law Married	Occupational status  Please choose Employed Retired Student - High school/Other Student - Full-time post-secondary Student - Part-time post-secondary Not currently employed Other

Please fill out only if you selected Student  or Other as Occupation:

Is this driver living away from their parent or guardian's home?                          Please choose Yes No

How far away is the parent or guardian's home from where this student lives?     Please choose 0 - 79 km 80 - 100 km 101 - 150 km 151 - 160 km 161 km or over

Licensing information:

Current type of licence?     G (full, unrestricted licence) G2 (intermediate level) G1 (first level, written test) Other province (not Ontario) USA United Kingdom Australia New Zealand Other country

When was this licence received?       Month January February March April May June July August September October November December Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908

Did this driver ever hold a G2 licence? Please choose Yes No

When was the G2 licence received?   Month January February March April May June July August September October November December Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994

Did this driver have a G1 licence?        Please choose Yes No	When was the G1 licence received?   Month January February March April May June July August September October November December Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994
Licence suspended in last 6 yrs?**      Please Choose No Once Twice 3 or more times	If any suspensions exist please Request a Call to discuss options.

Driving History:
Approved Canadian driving course?                  Yes No	Any accidents, tickets or claims?  Please choose Yes No

How many accidents or claims in last 10 years? Please choose None 1 2 3 More than 3	if yes Request a Call to discuss options.
How many tickets (convictions) in last 3 years?  Please choose None 1 2 3 4 5 More than 5	if yes Request a Call to discuss options.

How many non-accident claims (theft, windshield, etc...) in last 6 years  Please choose None 1 2 3 More than 3	if yes Request a Call
Insurance information:

Auto Insurance Policy cancelled by an insurance company in last 3 years?  Please choose No Once 2 times or more	If yes Request a Call
Currently insured as a primary or occasional driver on a Canadian or US auto insurance policy?  Please choose Primary Occasional

Insured in Canada or US in last 6 years?       Please choose Yes No	If No! Please Request a Call
Years of continuous insurance? Please choose Less than 1 year More than 1 and less than 2 More than 2 and less than 3 More than 3 and less than 4 More than 4 and less than 5 More than 5 and less than 6 More than 6 and less than 7 More than 7 and less than 8 More than 8 and less than 9 More than 9 and less than 10 More than 10 and less than 11 11 or more years	Months of Continuous Insurance? Please choose 0 1 2 3 4 5 6 7 8 9 10 11 or more

Expiry date of current Auto Insurance Policy                            Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Year 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908

When do you want the New Auto Insurance Policy to begin?    Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Year 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908

Vehicle information:

Make of Vehicle         Please Choose ACURA ALFA ROMEO AM GENERAL ASTON MARTIN AUDI BENTLEY BMW BUICK CADILLAC CHEVROLET/GEO CHRYSLER COLT DAEWOO DAIHATSU DODGE EAGLE FERRARI FORD GMC HONDA HUMMER HYUNDAI INFINITI ISUZU JAGUAR JEEP KIA LADA LAMBORGHINI LAND ROVER LEXUS LINCOLN LOTUS MASERATI MAYBACH MAZDA MERCEDES-BENZ MERCURY MINI MITSUBISHI MORGAN NISSAN OLDSMOBILE OPTIMA PEUGEOT PLYMOUTH PONTIAC PORSCHE ROLLS ROYCE SAAB SATURN SCION SMART STERLING SUBARU SUZUKI TOYOTA TVR VOLKSWAGEN VOLVO

Model of Vehicle

Year of Vehicle           Please choose 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 and prior

Is vehicle leased? Please choose Yes No

When purchased or leased? January February March April May June July August September October November December Year 2010 2009 2008 2007 2006 2005 and prior

Current value of vehicle  Please choose $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $11,000 $12,000 $13,000 $14,000 $15,000 $16,000 $17,000 $18,000 $19,000 $20,000 $21,000 $22,000 $23,000 $24,000 $25,000 $26,000 $27,000 $28,000 $29,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $105,000 $110,000 $115,000 $120,000 $125,000 $130,000 $135,000 $140,000 $145,000 $150,000

How many kilometres driven/year?

Daily kilometres driven to school/work (one-way)

Kilometres driven for business/year

Purpose of business use   Please Choose Accountant Artisan Auto Parts & Accessories Bakeries and Distributors Butcher Caterer Cleaning Company Contractors Courier Service Car Dealership Associate Delivery - Retail Delivery - Carrying Passengers Farmer Garage Associate Industrial Vehicles Landscape Service Real Estate Agent Sales Representative Snow Plough Service Taxi Service Other - Not carrying tools or equipment Other - Carrying tools or equipment

Alarm Systems                                 None 1 2 3	Theft Protection       Please choose Audible Boomerang Electronic Immobilizer Impact Mechanical Immobilizer Monitored Tracking VIN etching Intensive Anti-theft marking (Sherlock)
Install 4 winter tires in winter months?  Please Choose Yes No	Parking at home?         Please Choose Carport Private Driveway Private Garage Street Parking Lot Underground Parking Storage Other

Discounts:

Do you want a multi-line discount applied to this quote? (This means your home, tenant or condo policy will be with the insurer who also provides your auto coverage)

Please Choose Yes No

Do you currently have a home, tenant or condo insurance policy?

Please Choose No Yes - Home Yes - Tenant Yes - Condo

When does this property insurance policy expire?

Month January February March April May June July August September October November December Year 2010 2009 2008

How long has the policyholder been insured with their current insurance company?

Please choose Not insured/Less than 1 year More than 1 and less than 2 More than 2 and less than 3 More than 3 and less than 4 More than 4 and less than 5 More than 5 and less than 6 More than 6 and less than 7 More than 7 and less than 8 More than 8 and less than 9 9 or more years