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Please Complete the Form Below to Request a Quote:

*Required fields

*First Name:
 *Last Name:
*Phone:
 *Email:
*Address:
*City:
*State/Province:
*ZIP/Postal Code:
Have you ever had an insurance cancelled or refused? Yes No
Are you currently insured? Yes No
If not, have you had insurance for 12 consecutive months within the last 6 years? Yes No
When should coverage start? (dd/mm/yyyy)

Driver(s) Information:
Driver #1
Name of Driver:
Date of Birth:
Drivers Licence #:
Years licenced in Canada:
Licence class:
Sex:
Marital Status:
Driving School:
Retired?
Minor traffic convictions in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
How long have you had continuous insurance coverage?
Driver #2
Name of Driver:
Date of Birth:
Drivers Licence #:
Years licenced in Canada:
Licence class:
Sex:
Marital Status:
Driving School:
Retired?
Minor traffic convictions in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
How long have you had continuous insurance coverage?
Driver #3
Name of Driver:
Date of Birth:
Drivers Licence #:
Years licenced in Canada:
Licence class:
Sex:
Marital Status:
Driving School:
Retired?
Minor traffic convictions in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
How long have you had continuous insurance coverage?
Have any of above drivers had their licenses suspended or lapsed in the past 6 years? Yes No
Have any of the drivers above had accidents or claims in the past 10 years? Yes No

Claims Information:
# of Claims Date (mm/yyyy) Driver Involved
#1:
#2:
#3:

Vehicle Information:
Vehicle #1
Vehicle make:
Year:
Model:
Type:
Style:
Use:
KM driven one way to work:
Kilometres driven per year:
Who is primary driver:
Coverage Required:
Liability:
Collision deductible:
Comprehensive deductible:
Vehicle #1
Vehicle make:
Year:
Model:
Type:
Style:
Use:
KM driven one way to work:
Kilometres driven per year:
Who is primary driver:
Coverage Required:
Liability:
Collision deductible:
Comprehensive deductible:

How would you like to be contacted?
Phone Email
What is your occupation?
How did you hear about Maple Insurance?



 

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