Year(s), Make(s), Model(s) of Vehicle

When was this car purchased?

Purchase Price of Vehicle

Number of KM on Vehicle at Purchase

Describe your vehicle at purchase
NewUsed

Ownership Type
OwnFinanceLease

Other licensed drivers at same address?
YesNo

Will other licensed drivers need to be added to policy?
YesNo

First Time Insured in Ontario – What year did you first get insured? (You may have been listed under a different named policy)

Are you currently Insured? If yes, how long have you been with your current carrier?

Any claims in the past 10 years? If yes, detail all in concerns box below.
YesNo

Any cancellations for non-payment in past 3 years? If yes, detail in concerns box below.
YesNo

Do you have winter tires?
YesNo

Driver school certificate? (You will need to show proof)
YesNo

Type of vehicle use
PersonalCommercialUber

Average KM per year
Under 10,000km10,000 to 25,000kmAbove 25,000km

KM 1 way to work
Under 10km10 to 50kmOver 50km

Vehicle parking location
GaragePrivate DrivewayShared DrivewayRoadSecured Underground Parking

Vehicles to insure
12345 or more