The Insurance Exchange - London Ontario Insurance

Auto Insurance Quote

First Name:
Last Name:
Street Address:
City:
Province:
Postal Code:
Home Telephone Number:
Work Telephone Number:	ext
Email:

Currently Insured?
Current Insurance Expiry Date:
How Long Continuously Insured?
If not currently insured when was the last time insured

Drivers -

Please complete the following for ALL licensed drivers in your household.

Name

Date of Birth

Gender

Date G1 Licensed*

Date G2 Licensed*

Date G Licensed*

Driver Training Cert.?

Marital Status

Relationship to Insured

Driver #1

Driver #2

Driver #3

Driver #4

Vehicle Information -

Please complete the following for all vehicles you wish to have quoted.

Year

Make

Model

Vehicle Type

Liability Limit

All Perils*

Collision*

Comprehensive*

Other Coverage

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

*If this coverage is required please indicate the deductible you would like quoted.

Vehicle Use -

Please indicate the percentage of time each vehicle is operated by each driver and the use of each vehicle by each driver. If the vehicle is used to commute please indicate the km one way.

Driver #1 % use

Driver #1 Desc.

Driver #2 % use

Driver #2 Desc.

Driver #3 % use

Driver #3 Desc.

Driver #4 % use

Driver #4 Desc.

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Accidents & Claims -

Please complete the following including all accidents or claims for the last six years. All accidents, at fault or not at fault, involving any driver or vehicle owned by a listed driver must be included whether a claim was made or not and whether the vehicle is still owned or not. All claims made must also be included.

No accidents or claims in the last 6 years.

Incident #	Date of Incident	Driver	Vehicle	Paid Out ($)	Description
1
2
3
4
5

Driving Convictions (Tickets) -

Please list all tickets for all drivers in the household for the last three years. Every ticket except a parking ticket “Counts”.

No tickets to report for the past 3 years.

Ticket #	Driver	Date of Incident	Description of Ticket
1
2
3
4
5
6
7

Licence Suspensions or Lapses -

Please list all licence suspensions or lapses for all drivers in the household for the last six years.

No suspension or lapses to report for the past 6 years.

Driver	Date Suspended	Date Reinstated	Reason for Suspension

Insurance Policy Cancellations -

Please list all policy cancellations for all drivers in the household for the last three years.

No cancellations to report for the past 3 years.

Insurance Company	Date Cancelled	Reason for Cancellation

Additional Information -

Please provide us with any additional information that you feel may be important in assessing your quote.