Auto Insurance Form

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Driver 1
Driver 2
Driver 3
Name:
Age:
Years Licensed in Canada:
Driver's License #:
License Class:
Aquire Class of Driver's License :
G1
G2
G
G1
G2
G
G1
G2
G
Gender:
Marital Status:
Driving School?
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Minor Traffic Convictions in the past 3 years:
Major Traffic Convictions in the past 3 years:
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You are authorizing that we collect, use or disclose your personal information contained on this information form as well as any additional information that we may obtain about you and other listed beneficiaries based on the information you have disclosed to us, (for example confirming your claims history or checking with motor vehicle agencies), for the purpose of providing you with this quote. By submitting this information form you also confirm that you have obtained the permission of all other potential beneficiaries listed on this information form for the collection, use and disclosure of their Personal Information for the purpose of providing you with this quote. Submission of this form does not constitute an application for insurance.

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Thank you for taking the time to fill out this form. Select the "Submit" button below and we will contact you within the next two business days. Our quote will include the coverages you selected plus the standard Accident Benefits coverages. We will include the cost of popular optional coverages with our quotation. Optional Accident Benefit coverages can be upgraded by consulting one of our brokers. * Coverage is subject to the insurer's underwriting policies.