*(denotes required field)

E-Mail Address:

--- About You ---
Name(s) of insured(s):

1st insured:

2nd insured:

How can we reach you?

E-Mail Phone

Daytime telephone #:

Home telephone #:

Fax #:

--- New Vehicle ---

Vehicle make:

Year:

Model:

Condition at time of purchase:

New Demo Used

Purchase Date:

Purchase Price:

VIN (vehicle ID #):

Any non-factory modifications to the vehicle?

Yes No

Any unrepaired damage?

Yes No

If yes, specify:

Is vehicle leased or financed?

Please select... No Leased Financed

Names and address of leasing company lien holder:

Use of vehicle:

Pleasure Commuting Business Farming Other

Comments (details if use is other):

Kilometres traveled per year:

0-5000 5001-10000 10001-15000 15001-20000 20001-25000 25001-30000 30001-over

How many kilometers one-way for daily commute?

N/A 0-5 6-8 9-16 17-24 25+

Will adding this vehicle result in changes in use of other vehicles owned?

Yes No

Error: A select field is not configured properly in settings.

Third party Liability coverage requested:

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Collision coverage and deductible requested:

No Coverage
Yes - deductible (min) $500
Yes - deductible $1000
Yes - higher deductible (specify below)

Deductible requested:

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Comprehensive coverage and deductible requested:

No Coverage
Yes - deductible (min) $300
Yes - deductible $500
Yes - higher deductible (specify below)

Deductible requested:

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All perils coverage and deductible requested:

No Coverage
Yes - deductible (min) $500
Yes - deductible $1000
Yes - higher deductible (specify below)

Deductible requested:

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--- Driver Information ---
(for all drivers who will be operating this vehicle)

--- Driver #1 ---

Driver:

Date of Birth:

Driver type:

Principal Occasional

--- Driver #2 ---

Driver:

Date of Birth:

Driver type:,Principal;Occasional

--- Driver #3 ---

Driver:

Date of birth:

Driver type:

Principal Occasional

--- Effective Date ---

When will this change be effective?

--- About Your Insurance ---
(Specify the policy to which this change applies)

Company:

Policy #:

Additional Comments:

Name of your broker:

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