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Contact Information
Name
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Phone
Car Insurance Quote
1 / 10
2 / 6
Location Details
Address
City
Province
Postal Code
3 / 6
Insured's Details
Principal Driver
Date of Birth
Marital Status
# of Drivers in Household
Vehicle Information
Year
Make
Model
VIN
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Is the vehicle owned or leased?
Owned
Leased
Does the vehicle have winter tires?
Yes
No
4 / 6
Vehicle Usage
Annual KM
Years continuously insured
Years with current insurance provider
5 / 6
Is the vehicle used for pleasure or commuting?
Pleasure
Commute
If for commuting, how many KM one-way?
4 / 6
Did you complete driver training?
Yes
No
Have you ever had your licensed suspended?
Yes
No
Date Suspended
Reason
4 / 6
Indicate each license you have obtained and the number of years licensed.
G
G2
G1
Have you ever had lapse in coverage?
Yes
No
Reason
4 / 6
Other details:
Describe any convictions:
Describe any accidents
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