REQUEST A QUOTE:  
|
|
|


Automobile Insurance Quote Form
Please complete the following form to receive a quick quote.

Personal Information
         
First Name:
 
Last Name:
   
 
Address:
   
 
City/Town:
  
Province:
   
 
Postal Code:
 
 
   
 
Home Phone:
 
Work Phone:
   
 
Fax:
  
Email:
   
 
Have you ever had an automobile insurance policy cancelled or declined?
Yes No
   
 
If yes, please provide details:
   
 
Vehicle/Driver Information
   
 
Vehicle #1:      
Year of Vehicle:
Make:
Model:
Body Type:
       
Registered Owner:
      
       
Principal Driver:
  
Male/Female:
M F
Years Continuously Licensed:
  
Years Continuously Insured:
Current Occupation:
  
Claims/Convictions in Past 6 Years?
   
 
Occasional Driver(s):
  
Male/Female:
M F
Years Continuously Licensed:
  
Years Continuously Insured:
Current Occupation:
  
Claims/Convictions in Past 6 Years?
   
 
Occasional Driver(s):
  
Male/Female:
M F
Years Continuously Licensed:
  
Years Continuously Insured:
Current Occupation:
  
Claims/Convictions in Past 6 Years?
   
 
Distance Commuted to Work (one way):
  
Business Use?
 Yes No

Kilometers Traveled Per Year:

  
 
Are there any drivers under the age of 25?
 Yes No  
Driver Education?
Yes No
         
         
Vehicle #2:      
Year of Vehicle:
Make:
Model:
Body Type:
       
Registered Owner:
      
       
Principal Driver:
  
Male/Female:
M F
Years Continuously Licensed:
  
Years Continuously Insured:
Current Occupation:
  
Claims/Convictions in Past 6 Years?
   
 
Occasional Driver(s):
  
Male/Female:
M F
Years Continuously Licensed:
  
Years Continuously Insured:
Current Occupation:
  
Claims/Convictions in Past 6 Years?
   
 
Occasional Driver(s):
  
Male/Female:
M F
Years Continuously Licensed:
  
Years Continuously Insured:
Current Occupation:
  
Claims/Convictions in Past 6 Years?
   
 
Distance Commuted to Work (one way):
  
Business Use?
 Yes No

Kilometers Traveled Per Year:

  
 
Are there any drivers under the age of 25?
 Yes No  
Driver Education?
Yes No
         
Required Coverage
 
Vehicle #1
 
Vehilce #2
 
Third Party Liability:
 
 
Collision Deductible:
 
 
Comprehensive Deductible:
 
 
         
Additional Endorsements  
         
Rental Vehicle:
Waiver of Depreciation:
Deletion of Glass:
Reduction of Coverage for Named Operator:
Legal Liability for Non-owned Vehicles:

 

        
Please provide any details on claims/convictions in the past 6 years:
         
Please provide any additional relevant information:
         

1262 Bedford Highway Bedford, Nova Scotia Canada B4A 1C7
Tel: (902) 835-1262 Fax: (902) 835-2604 Toll free 1-877-925-2285