1st Insured: *FirstLast2nd InsuredFirstLastHow can we reach you: *EmailPhoneEmail *Telephone Number *Fax NumberNew Vehicle: Vehicle Make *Year *Model *Condition at the time of purchase *NewDemoUsedPurchase Date *Purchase Price *VIN *Any non-factory modifications to the vehicle? *YesNoIf yes please specifyAny unrepaired damage? *YesNoIf yes please specifyIs the vehicle leased or financed *YesNoIf yes please specifyName of Registrant *FirstLastUse of Vehicle *PleasureCommutingBusinessFarmingOtherComments (details if use is other)Kilometres travelled per year *0-5,0005,001-10,00010,001-15,00015,001-20,00020,001-25,00025,001-30,00030,000+How many kilometers one-way for daily commute *N/A0-56-89-1617-2425+Will replacing this vehicle result in changes in use of other vehicles owned? *YesNoThird party liability coverage requested$1,000,000$2,000,000Collision coverage and deductible requested *none$500$1000HigherIf Higher, please specifyComprehensive coverage and deductible requested *none$300$500HigherIf Higher, please specifyAll perils coverage and deductible requested *none$500$1000HigherIf Higher, please specifyDriver #1 Name *FirstLastDate of Birth *Driver Type *PrincipalOccasionalDriver #2 NameFirstLastDate of BirthDriver TypePrincipalOccasionalDriver #3 NameFirstLastDate of BirthDriver TypePrincipalOccasionalDate when this change will be effective *About your Insurance: Company *Policy # *Additional CommentsName of your brokerFirstLastPhoneSubmit
