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When should coverage start: |
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Are you currently insured: |
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Have you ever had insurance cancelled or refused*: |
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Do you currently insure your car: |
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If not, have you had insurance for 12 consecutive months within the last 6 years: |
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Driver Information |
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Name: |
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Drivers License #:* |
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Years licensed in Canada:* |
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Date G1 Obtained: |
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Date G2 Obtained: |
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Date G Obtained: |
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Sex: |
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Marital Status: |
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Driving School: |
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Retired? |
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Minor traffic convictions in
the last 3 yrs: |
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Major traffic convictions in
the last 3 yrs (careless or
impaired driving, refusing
breathalyzer, etc.): |
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Have any of above drivers had their licenses suspended or revoked in the past 3 years: |
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Have any of the drivers above had accidents or insurance in the past 6 years*: |
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Claims Information: |
Claims |
Date |
Driver Involved |
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#1: |
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#2: |
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#3: |
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Vehicle Information |
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Vehicle Make: |
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Year: |
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Model: |
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Style: |
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Use: |
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Kilometres driven per year: |
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Who is primary driver: |
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Coverage Required: |
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Liability: |
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Collision deductible: |
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Comprehensive deductible: |
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