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First Name *

Last Name *

Email Address *

Phone *

Address *

City *

Province *

Postal Code *

Date of Birth: Select date... *

When should your new coverage start? Select date... *

How would you like to be contacted? Phone Email *

What is your occupation?

How did you hear about us?

Are you currently insured? Yes No *

Have you ever had an insurance cancelled or refused? Yes No *

Have you had insurance for 12 consecutive months within the last 6 years? Yes No *

How long have you had continuous insurance coverage? Please select... 0 years 1 year 2 years 3 years 4 years 5 to 10 years Over 10 years Over 20 years *

License Class Please select... 1 2 3 4 5 6

Number of convictions in the past 3 years? Please select... 0 1 2 3+ *

Have you had your licenses suspended or lapsed in the past 6 years? Yes No *

Have you had accidents or claims in the past 10 years? Yes No *

How many insurance claims have you made in the past 10 years? Please select... None 1 2 3 4 5 Over 5 *

Please enter the number of drivers to be included on the policy: *

Name of Driver #2

Date of Birth (2nd Driver): Select date...

Driver's License #:

Number of years licensed in Canada:

License Class Please select... 1 2 3 4 5 6

Gender: Please select... Female Male

How long have you had continuous insurance coverage? Please select... 0 years 1 year 2 years 3 years 4 years 5 to 10 years Over 10 years Over 20 years

Number of convictions in the past 3 years? Please select... 0 1 2 3+

Have any of the drivers above had accidents or claims in the past 10 years? Yes No