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Please fill in the following form. We know that you may not know all the answers at this time, if you do not know the answer you can move onto the next section and we will assist you answering the questions later.

Applicant Information

Additional Applicant Details

First Name

Middle Name(s)

Last Name

Date of Birth

Mailing Address

Mailing Town/City

Mailing Postal Code

Home Phone

Fax Number

Work Phone

Email Address

Add Additional Applicant

Remove Additional Applicant

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Drivers

Additional Driver Details

First Name

Last Name

Birthday

License Number

Years Licensed

License Location

Class of License

Marital Status

Relationship to Applicant

Name of Employer

Occupation

Add Additional Driver

Remove Additional Applicant

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Insurance History

Previous Insurer

Policy Number

Years Continuously Insured

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Vehicle

Year

Make

Vehicle Model

Cylinders

Cylinder Volume (CCs)

Serial Number /VIN

Purchase Date

Purchase Price

Will the vehicle be driven to school or work? No Yes

Principal Vehicle Operator

Type of Vehicle Car/Truck/Van ATV Snowmobile Motorcycle

Is the vehicle used for business, taxi or rental?

No Yes

What is the exact use of the vehicle

Is the vehicle parked in the south?

No Yes

What address is the vehicle parked at?

Date of arrival in North

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General

Has any driver had any convictions arising from the operation of any automobile during the past three years?

No Yes

Date of Conviction

Type of Conviction

Is any driver subject to fainting spells, dizziness or loss of consciousness?

No Yes

Please Explain

Has any driver or vehicle had any accidents or claims arising from the operation of any automobile during the past six years?

No Yes

Date of Accident/Claim

Please Explain Previous Accident

Has any drivers license been suspended, cancelled or lapsed within the past six years?

No Yes

Please Explain

Has any insurance company cancelled, declined or refused to renew or issue automobile insurance to the applicant or drivers listed within 3 years preceding this application?

No Yes

Insurer Involved

Policy Number

State the name(s) of the legal owner of this vehicle. This must match the bill of sale.

Who will be the registered owner of this vehicle

Is the vehicle under lease or finance or is it paid in full?

Lease Finance Paid in Full

Name of the LeasingFinancing Company

Address of Company

Will the automobile be rented or leased to others?

No Yes

Will the automobile carry passengers for compensation?

No Yes

Will the automobile carry explosives of radioactive material?

No Yes

State the total number of private passenger vehicles in the household including this one

State the total number of licensed drivers in the household including those already listed

Non-Licenced Members of Household

If there are any non-licensed members of the household (over the age of 16) please enter their names and dates of birth

Household Member Name

Birthdate

Add Household Member

Remove Household Member

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Coverage

Third Party Liability

Mandatory $200,000 $500,000 $1,000,000 $2,000,000

Collision Coverage

No Yes

Coverage Amount $250 $500 $1000

Comprehensive Coverage

No Yes

Coverage Amount $100 Deductible $250 Deductible $500 Deductible $1000 Deductible

SEF #20 (Rental Car Coverage after an accident)

Decline Accept

SEF #27 (Replaces rental car agency coverages)

Decline Accept

SEF #43 (Waiver of Depreciation on brand new vehicles)

Decline Accept

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Applicant Information

Additional Applicant Details

Drivers

Additional Driver Details

Insurance History

Vehicle

Is the vehicle used for business, taxi or rental?

Is the vehicle parked in the south?

General

Has any driver had any convictions arising from the operation of any automobile during the past three years?

Is any driver subject to fainting spells, dizziness or loss of consciousness?

Has any driver or vehicle had any accidents or claims arising from the operation of any automobile during the past six years?

Has any drivers license been suspended, cancelled or lapsed within the past six years?

Has any insurance company cancelled, declined or refused to renew or issue automobile insurance to the applicant or drivers listed within 3 years preceding this application?

State the name(s) of the legal owner of this vehicle. This must match the bill of sale.

Who will be the registered owner of this vehicle

Is the vehicle under lease or finance or is it paid in full?

Will the automobile be rented or leased to others?

Will the automobile carry passengers for compensation?

Will the automobile carry explosives of radioactive material?

State the total number of private passenger vehicles in the household including this one

State the total number of licensed drivers in the household including those already listed

Non-Licenced Members of Household

If there are any non-licensed members of the household (over the age of 16) please enter their names and dates of birth

Coverage

Third Party Liability

Collision Coverage

Comprehensive Coverage

SEF #20 (Rental Car Coverage after an accident)

SEF #27 (Replaces rental car agency coverages)

SEF #43 (Waiver of Depreciation on brand new vehicles)