Auto Insurance Quotes

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If you are unsure of how to complete the form, have a question regarding your coverages or how the claim will be handled, please contact our office during regular business hours.

PERSONAL INFORMATION

Name: *

Email: *

Phone: *

Work:

Fax:

Address: *

City: *

Province:

Country:

Postal Code: *

CURRENT POLICY INFORMATION

Present Insurance Company:
(NOT the broker name)

Policy Number:

Expiry Date:

ACCIDENTS, CLAIMS OR CONVICTIONS

Have you had any accidents, claims or convictions in the the last 5 years? If so, we need details. *

VEHICLE INFORMATION

	Vehicle 1	Vehicle 2
Year: *
Body Type: *
Make: *
Model: *
Vehicle Use / Class: *
Licence Plate#: *
Leased? *	Yes No	Yes No
Has the glass been damaged? *	Yes No	Yes No
INSURANCE COVERAGE REQUIRED
Liability: *
Comprehensive Deductible: *
Collision Deductible: *
Loss of Use:	(replacement car coverage)	(replacement car coverage)
Waiver of Depreciation:	(new vehicles only)	(new vehicles only)

How would you prefer to be contacted? *
Email: Home: Work Fax:

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