* – Required

First Name *: Last Name *:
Email *:
Address:
City: Province: Postal Code *
Phone: Phone/Other:
Vehicle
Vehicle Year *
Vehicle Make *
Vehicle Model *
Vehicle Serial Number *
Vehicle Registration Number *
Anti-Theft * Yes No
Type(s) of Anti-Theft Used
(e.g. passive, immobilizer, alarm)
Drivers
Principle Driver
Driver’s Licence # *
If not listed in BC, indicate number of years claims free
Number of years driving in Canada / USA *
Number of years driving worldwide *
Occasional Driver(s)
All occasional drivers in household have held a valid driver’s license for at least 10 years. * Yes No
Vehicle Use
Coverage
Collision Deductible *
$300 $500 $1000 $2500

Comprehensive Deductible *
$300 $500 $1000 $2500

Third Party Liability *
Loss of Use * 
Yes No
Comments:

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