*indicates required field
Name *
Email *
Address
City
Province
Postal Code*
Vehicle*
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Serial Number
Vehicle Registration Number
Anti-Theft
Yes
No
Type(s) Used
(e.g. passive, immobilizer, alarm)
Drivers*
Principle Driver
Driver's Licence #
If not listed in BC, indicate number of years claims free
Number of years driving in Canada / USA
Number of years driving worldwide
Occasional Driver(s)
All occasional drivers in household have held a valid driver's license for at least 10 years.
Yes
No
Vehicle Use
Pleasure Use
To/From work or school within 15kms
To/From work or school beyond 15kms
Part way to/from work or school
Business Use
Delivery or Commercial Use
Artisan Use
Senior Use (Pleasure use only for drivers aged 65+)
Coverage*
Collision Deductible
$300
$500
$1000
$2500
Comprehensive Deductible
$300
$500
$1000
$2500
Third Party Liability
Loss of Use
Yes
No
Comments
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