Car Insurance Quote Request

Please fill out this form as completely as you can to help us give you an accurate quote.

We'll get back to you as soon as possible. Don't forget to include your correct, complete name, phone number and email address.

***Please note we are unable to quote outside the provinces of New Brunswick and Nova Scotia.

 
Your Name:
Street:
City:
Province:
Postal Code:
Day Phone:
Your e-mail:
Best time to contact:
Are you presently
insured?
Present
insurance carrier:
Do you own
a home?
How did you learn
about this website?
 

Driver Information
Driver 1 Driver 2 Driver 3
Name
Sex
Marital status
Date of birth
(month/day/year)
Date licensed
(month/day/year)
Driver Training?


Any "at fault" accidents in the last 6 years?
"at fault" accidents
If Yes add details (include dates, amounts paid and description of claim).
"at fault" details


Any traffic violations or convictions in the past 3 years?
Traffic Violations or Convictions
If "Yes" add details (include dates, and type of conviction)
traffic violation/ conviction details.


Has any license been suspended in last 6 years?
Licence suspension

How long have you been continuously insured?
Continuous insurance
 

Vehicle Information
Vehicle 1 Vehicle 2 Vehicle 3
Year
Make
Model
2 door/4 door
 
Vehicle Use: 
  • Pleasure only
  • Driven to and from work less than 16km one way.
  • Driven to and from work greater than 16km one way.
  • Business use.
  • Used only on a farm (For full time farmers only).
Vehicle use

Vehicle #1

Vehicle #2

Vehicle #3
Kilometers driven annually

   
Third party Liablility
Accident Benefits compulsory compulsory compulsory
Uninsured Motorist Coverage compulsory compulsory compulsory
Health Services Levy compulsory compulsory compulsory
Collision Deductible
Comprehensive Deductible


Endorsements (Select the ones you want)
Loss of Use SEF #20
Emergency Road Service SEF #35
Non-owned Auto Coverage SEF #27
Replacement Cost Coverage SEF #43
Family Protection
SEF #44

Please add any comments that may help us with your quote.
Comments: