Saturday, 27 July 2013

Auto Insurance Application



Basic Information

?Postal code?
?First name?
?Last name?
?Telephone number?  
?Email address?
?How many vehicles would you like to insure?
?How many drivers will be driving these vehicles?
?Effective date of the policy  

Driver Information - Driver 1 of 1

City or town of residenceCALGARY
?Street address?
?First name?
?Last Name?
?Date of birth?  
?Gender?
?Marital status?
?Occupation?

Licence Information

?Licence class?
?Date when you received your first drivers license in Canada?  
?Have you taken a driver training course and received a certificate in the past 3 years?

Driving History

?In what year were you first insured?
?How many years have you had continuous insurance coverage with your current insurance company?
?How many traffic tickets has this driver had in the past 3 years? (not parking tickets)
?How many claims, not involving collisions with vehicles or objects has this driver had in the past 10 years?
?How many accidents (regardless who was at fault) has the driver had in the past 10 years?
?How many times have you had your driver's license suspended in the past 6 years?
?How many times have you had your insurance coverage cancelled by an insurance company in the past 3 years?

Alberta Auto Reform Information

?Driver's grid level? (leave blank if unknown)
?Grid level relevant date? (if unknown, use current Alberta auto policy effective date)

Vehicle Information - Vehicle 1 of 1

?Vehicle year?
?Primary use for this vehicle?
?Kilometres driven annually?,000
?Vehicle anti-theft device?

Coverages

?Third Party Liability
?Collision Deductible
?Comprehensive Deductible
?Loss of Use (temporary replacement vehicle)
?Non-Owned Autos (vehicle rental coverage)
?Reduced Glass Coverage
In respect of this quotation, any policy we issue and subsequent renewals or changes; we may order reports containing personal, credit and investigative information. This information, solely relating to your automobile and/or personal property policy is used in order to assess risk, investigate and settle claims and detect and prevent fraud.

Do you authorize us to collect, use and disclose this information to appropriate third parties?
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