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AUTO INSURANCE
PROPERTY INSURANCE
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COMMUNITES
CONTACT
Manual Auto Quote Form
Manual Auto Quote Form
adminpower
2020-10-27T20:30:29+00:00
Pre-Requisite Questions
Are you currently a resident of Ontario Canada?
*
Yes
No
Sorry, you must be a resident of Ontario Canada to apply for a quote.
Will the vehicle now, or in the future be used for Uber driving?
*
Yes
No
Sorry, we cannot provide insurance for vehicles used for Uber driving.
Is the vehicle you wish to insure over 20 years old?
*
No
Yes
Sorry, we cannot insure vehicles over 20 years of age.
How many vehicles require insurance?
*
One
Two
Three +
Sorry, this form can only accept up to two vehicles. We can still provide you a quote by telephone. Please call our office directly 1.877.373.3133.
How many drivers will you list?
*
One (Applicant is Driver #1)
Two (Referred to as Driver #2)
Three (Referred to as Driver #3)
Four +
Drivers include anyone over the age of 16 that live in the same household who DO NOT have their own auto insurance.
Sorry, this form can only accept up to two vehicles and three drivers. We can still provide you a quote by telephone. Please call our office directly 1.877.373.3133.
Applicant Information (Driver #1)
Name
*
First
Last
Gender
*
Male
Female
Street Address
*
City
*
Postal Code
*
Phone
*
Email
*
Enter Email
Confirm Email
Vehicle #1 Information
Year
*
Select ...
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Make
*
Select ....
Acura
Audi
BMW
Buick
Cadillac
Chevrolet
Chrysler
Dodge
Fiat
Ford
GMC
Honda
Hyundai
Hummer
Infiniti
Jaguar
Jeep
Kia
Land Rover
Lexus
Lincoln
Mazda
Mercedes-Benz
Mercury
Mini
Mitsubishi
Nissan
Oldsmobile
Plymouth
Pontiac
Porsche
Saab
Saturn
Scion
Smart
Subaru
Suzuki
Toyota
Volkswagen
Volvo
Model
*
17 Digit VIN #
Purchase Month
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Purchase Year
*
Select ...
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Type of coverage
*
Select ...
Liability, Collision, Comprehensive and Loss of Use
Liability Only
KMs driven to work/school (One Way)
*
Select ...
Under 10 Kms
11 to 24 Kms
25 to 49 Kms
50 and over Kms
KMs driven overall (Yearly)
*
Select ...
10,000 and under
11,000 to 24,000
25,000 or more
Vehicle #2 Information
Year
*
Select ...
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Make
*
Select ....
Acura
Audi
BMW
Buick
Cadillac
Chevrolet
Chrysler
Dodge
Fiat
Ford
GMC
Honda
Hyundai
Hummer
Infiniti
Jaguar
Jeep
Kia
Land Rover
Lexus
Lincoln
Mazda
Mercedes-Benz
Mercury
Mini
Mitsubishi
Nissan
Oldsmobile
Plymouth
Pontiac
Porsche
Saab
Saturn
Scion
Smart
Subaru
Suzuki
Toyota
Volkswagen
Volvo
Model
*
17 Digit VIN #
Purchase Month
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Purchase Year
*
Select ...
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Type of coverage
*
Select ...
Liability, Collision, Comprehensive and Loss of Use
Liability Only
KMs driven to work/school (One Way)
*
Select ...
Under 10 Kms
11 to 24 Kms
25 to 49 Kms
50 and over Kms
KMs driven overall (Yearly)
*
Select ...
10,000 and under
11,000 to 24,000
25,000 or more
Applicant (Driver #1) Information
Birth Day
*
Select ...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Month
*
Select ...
January
February
March
April
May
June
July
August
September
October
November
December
Birth Year
*
Select ...
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Applicant: Status
*
Select ...
Married
Single
Common Law
Applicant: Did you acquire your license prior to 1994?
*
Select ...
Yes
No
Applicant: Month G license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Applicant: Year G license was obtained
*
Select ...
Before 1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
Applicant: Month G license was obtained (Optional)
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Applicant: Year G license was obtained (Optional)
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Applicant: Month G2 license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Applicant: Year G2 license was obtained
*
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Applicant: Month G1 license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Applicant: Year G1 license was obtained
*
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Applicant: Did you take certified driver training?
*
Select ...
No
Yes
Applicant: How many years of CONTINUOUS insurance have you held in the past 15 years?
*
Select ...
None
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
Applicant: Current Insurance Status
*
Select ...
Insured
Un-Insured
Applicant: Why are you un-insured?
*
Select ...
Non-Payment
Non-Renewed
Non-Disclosure
Self Cancelled
No Prior Insurance
Other
Applicant: What is the Expiry Date of your current or last policy?
*
MM slash DD slash YYYY
Applicant (Driver #1) Driving History
Applicant: How many AT FAULT accidents in past 6 years?
*
Select ...
None
One
Two
Three
Four
Five +
Date of Accident #1
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #2
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #3
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #4
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Applicant: How many TICKETS in the past 3 years?
*
Select ...
None
One
Two
Three
Four
Five
Six
Seven
Eight +
Date of Conviction #1
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #1
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #2
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #2
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #3
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #3
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #4
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #4
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #5
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #5
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #6
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #6
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #7
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #7
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Applicant: In the past 6 years, how many times has your license been suspended for OVER 30 days?
*
Select ...
Never
Once
Twice
Three times
More than three times
Reason for Suspension #1
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #1
*
DD slash MM slash YYYY
Date of Reinstatement #1
*
DD slash MM slash YYYY
Reason for Suspension #2
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #2
*
DD slash MM slash YYYY
Date of Reinstatement #2
*
DD slash MM slash YYYY
Reason for Suspension #3
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #3
*
DD slash MM slash YYYY
Date of Reinstatement #3
*
DD slash MM slash YYYY
Applicant: How many times has your policy been cancelled for NON-PAYMENT in the past 3 years?
*
Select ...
Never
Once
Twice
Three times
More than three times
Date of 1st Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of 2nd Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of 3rd Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Applicant: Have you ever been cancelled for NON-DISCLOSURE or MIS-REPRESENTATION?
*
Select ...
Yes
No
Driver #2 Information
Driver #2: Name
*
First
Last
Driver #2: Gender
*
Male
Female
Birth Day
*
Select ...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Month
*
Select ...
January
February
March
April
May
June
July
August
September
October
November
December
Birth Year
*
Select ...
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Driver #2: Status
*
Select ...
Married
Single
Common Law
Driver #2: Acquire license prior to 1994?
*
Select ...
Yes
No
Driver #2: Month G license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #2: Year G license was obtained
*
Select ...
Before 1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
Driver #2: Month G license was obtained (Optional)
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #2: Year G license was obtained (Optional)
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Driver #2: Month G2 license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #2: Year G2 license was obtained
*
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Driver #2: Month G1 license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #2: Year G1 license was obtained
*
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Driver #2: Take certified driver training?
*
Select ...
No
Yes
Driver #2 How many years of CONTINUOUS insurance held in the past 15 years?
*
Select ...
None
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
Driver #2: Current Insurance Status
*
Select ...
Insured
Un-Insured
Driver #2: Why un-insured?
*
Select ...
Non-Payment
Non-Renewed
Non-Disclosure
Self Cancelled
No Prior Insurance
Other
Driver #2: What is the Expiry Date of your current or last policy?
*
MM slash DD slash YYYY
Driver #2: Driving History
Driver #2: How many AT FAULT accidents in past 6 years?
*
Select ...
None
One
Two
Three
Four
Five +
Date of Accident #1
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #2
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #3
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #4
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Driver #2: How many TICKETS in the past 3 years?
*
Select ...
None
One
Two
Three
Four
Five
Six
Seven
Eight +
Date of Conviction #1
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #1
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #2
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #2
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #3
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #3
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #4
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #4
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #5
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #5
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #6
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #6
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #7
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #7
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Driver #2: In the past 6 years, how many times has license been suspended for OVER 30 days?
*
Select ...
Never
Once
Twice
Three times
More than three times
Reason for Suspension #1
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #1
*
DD slash MM slash YYYY
Date of Reinstatement #1
*
DD slash MM slash YYYY
Reason for Suspension #2
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #2
*
DD slash MM slash YYYY
Date of Reinstatement #2
*
DD slash MM slash YYYY
Reason for Suspension #3
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #3
*
DD slash MM slash YYYY
Date of Reinstatement #3
*
DD slash MM slash YYYY
Driver #2: How many times has policy been cancelled for NON-PAYMENT in the past 3 years?
*
Select ...
Never
Once
Twice
Three times
More than three times
Date of 1st Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of 2nd Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of 3rd Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Driver #2: Have you ever been cancelled for NON-DISCLOSURE or MIS-REPRESENTATION?
*
Select ...
Yes
No
Driver #3 Information
Driver #3: Name
*
First
Last
Driver #3: Gender
*
Male
Female
Birth Day
*
Select ...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Month
*
Select ...
January
February
March
April
May
June
July
August
September
October
November
December
Birth Year
*
Select ...
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Driver #3: Status
*
Select ...
Married
Single
Common Law
Driver #3: Acquire license prior to 1994?
*
Select ...
Yes
No
Driver #3: Month G license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #3: Year G license was obtained
*
Select ...
Before 1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
Driver #3: Month G license was obtained (Optional)
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #3: Year G license was obtained (Optional)
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Driver #3: Month G2 license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #3: Year G2 license was obtained
*
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Driver #3: Month G1 license was obtained
*
Select ...
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Driver #3: Year G1 license was obtained
*
Select ...
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Driver #3: Take certified driver training?
*
Select ...
No
Yes
Driver #3: How many years of CONTINUOUS insurance held in the past 15 years?
*
Select ...
None
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
Driver #3: Current Insurance Status
*
Select ...
Insured
Un-Insured
Driver #3: Why un-insured?
*
Select ...
Non-Payment
Non-Renewed
Non-Disclosure
Self Cancelled
No Prior Insurance
Other
Driver #3: What is the Expiry Date of your current or last policy?
*
MM slash DD slash YYYY
Driver #3: Driving History
Driver #3: How many AT FAULT accidents in past 6 years?
*
Select ...
None
One
Two
Three
Four
Five +
Date of Accident #1
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #2
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #3
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of Accident #4
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Driver #3: How many TICKETS in the past 3 years?
*
Select ...
None
One
Two
Three
Four
Five
Six
Seven
Eight +
Date of Conviction #1
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #1
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #2
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #2
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #3
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #3
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #4
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #4
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #5
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #5
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #6
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #6
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Date of Conviction #7
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Reason Ticket #7
*
Select ...
Speeding (1-49 over limit)
Fail to have insurance card
Driver's license violation
Traffic sign or light
Minor unspecified
Driving with no insurance
Careless driving
Driving with G1 licence unaccompanied
Major unspecified
Alcohol related
Driving with suspended license
Dangerous driving
Speeding 50+ over limit
Serious unspecified
Driver #3: In the past 6 years, how many times has license been suspended for OVER 30 days?
*
Select ...
Never
Once
Twice
Three times
More than three times
Reason for Suspension #1
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #1
*
DD slash MM slash YYYY
Date of Reinstatement #1
*
DD slash MM slash YYYY
Reason for Suspension #2
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #2
*
DD slash MM slash YYYY
Date of Reinstatement #2
*
DD slash MM slash YYYY
Reason for Suspension #3
*
Select ...
Alcohol related
Non-payment of fine
Too many convictions or demerit points
Medical reasons
Criminal related
Date of Suspension #3
*
DD slash MM slash YYYY
Date of Reinstatement #3
*
DD slash MM slash YYYY
Driver #3: How many times has policy been cancelled for NON-PAYMENT in the past 3 years?
*
Select ...
Never
Once
Twice
Three times
More than three times
Date of 1st Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of 2nd Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Date of 3rd Cancellation
*
DD slash MM slash YYYY
Enter 1st day of the month if unsure of the exact date.
Driver #3: Have you ever been cancelled for NON-DISCLOSURE or MIS-REPRESENTATION?
*
Select ...
Yes
No
How did you hear about us?
*
Google
Bing
Other Search Engine
Radio Ad
Referral
Other
Phew ... all done!
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