|
Name
of the owner:
(or name of lessor, if it's
a leased vehicle) |
|
First
name of the owner:
(or first name of lessor,
if it's a leased vehicle) |
|
Address:
(include the postal code) |
|
| Telephones: |
|
| Email: |
|
| Gender: |
|
| Status: |
|
| Date
of birth: |
|
| Occupation: |
|
| Employer's
name: |
|
Present
insurer:
(name of the insurance company,
policy number and expiry date) |
|
| Quebec
driver's license since: |
|
Permit
suspended in the past:
(provide the details in Special
considerations, if applicable)
|
|
| Criminal
antecedants: |
|
Your
percentage of use:
(if you are the sole driver,
the answer is 100%) |
|
Driving
infractions in past 3 years:
(provide details for each
driver) |
|
Responsible
accidents in the past 6 years:
(provide dates, amounts, circumstances) |
|
Non-responsible
accidents in the past 6 years:
(provide details) |
|
Other
claims or incidents in the past 6 years:
(provide details) |
|
Other
drivers:
(provide all the details
as above) |
|
Year,
make and model of vehicle:
(if there have benn any modifications,
please specify under Special considerations) |
|
| Lease
or purchase: |
|
Name
and address of lienholder or leasing company:
(include the postal code)
|
|
| Anti-theft
system: |
|
| Boomerang
tracking system: |
|
Cancellation
or non-renewal of an insurance policy
in the past:
(provide the details in Special
considerations, if applicable) |
|
Coverages
requested :
(minimum deductible $250)
|
A ..-
Automobile Public Liability
B1 - All Perils
B2 - Collision or upset
B3 - Comprehensive
B4 - Specified perils
Replacement Cost
Car rental package
|
Deductible
desired:
(if you chose B1 or B2)
|
|
Deductible
desired:
(if you chose B3 or B4)
|
|
| What
vehicle is used for : |
|
| Total
kilometers annually: |
|
| If
the vehicle is used to go to work, indicate
the distance: |
|
| Special
considerations: |
|
| Digital
photos: |
|
|
|
|
