Request a quote:         Auto Insurance             Your Name: Email: Address: Telephone: City/Town:     Postal Code:         Currently Insured: --Select-- Yes No Current insurance expiry date: (even as an occasional operator)?     (dd/mm/yy)   How long continuously insured? --Select-- < 1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10+ years   If not currently insured when was the last time insured --Select-- Never < 1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10+ years             Drivers  Please complete the following for ALL licensed drivers in your household.             Driver #1 Driver #2 Driver #3 Driver #4 Name Date of Birth Sex --Select-- Female Male --Select-- Female Male --Select-- Female Male --Select-- Female Male Date G1 Licensed* Date G2 Licensed* Date G Licensed* Driver Training Cert.? Marital Status Relationship to Insured    Please indicate year and month each level was obtained. If the driver did not go through the graduated licensing program please indicate for the G level only. Please attach additional pages if there are more than four licensed drivers in your household.                     Vehicle Information Please complete the following for all vehicles you wish to have quoted.             Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4 Year Make Model Vehicle Type Liability Limit --Select-- $1,000,000 $2,000,000 $5,000,000 --Select-- $1,000,000 $2,000,000 $5,000,000 --Select-- $1,000,000 $2,000,000 $5,000,000 --Select-- $1,000,000 $2,000,000 $5,000,000 All Perils* --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 Collision* --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 Comprehensive* --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 --Select-- $300 $500 $1,000 OPCF’s Other Coverage Other Coverage    If this coverage is required please indicate the deductible you would like quoted.                     Vehicle Use Please indicate the percentage of time each vehicle is operated by each driver and the use of each vehicle by each driver. If the vehicle is used to commute please indicate the km one way.             Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4 Driver #1 - % Use Driver #1 - Desc. --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial Driver #2 - % Use Driver #2 - Desc. --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial Driver #3 - % Use Driver #3 - Desc. --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial Driver #4 - % Use Driver #4 - Desc. --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial --Select-- Pleasure Commute Business Commercial                     Accidents & Claims Please complete the following including all accidents or claims for the last six years. All accidents, at fault or not at fault, involving any driver or vehicle owned by a listed driver must be included whether a claim was made or not and whether the vehicle is still owned or not. All claims made must also be included.               No accidents or claims in the last 6 years.           Incident # Date of Incident Driver           Auto Paid Out ($)  Description 1 # 1 2 3 4      # 1 2 3 4 2 # 1 2 3 4      # 1 2 3 4 3 # 1 2 3 4      # 1 2 3 4 4 # 1 2 3 4      # 1 2 3 4 5 # 1 2 3 4      # 1 2 3 4 6 # 1 2 3 4      # 1 2 3 4 7 # 1 2 3 4      # 1 2 3 4 8 # 1 2 3 4      # 1 2 3 4 9 # 1 2 3 4      # 1 2 3 4 10 # 1 2 3 4      # 1 2 3 4                     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 # 1 2 3 4 2 # 1 2 3 4 3 # 1 2 3 4 4 # 1 2 3 4 5 # 1 2 3 4 6 # 1 2 3 4    If ticket was for speeding please indicate how many kilometres over the speed limit.                     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 # 1 2 3 4 # 1 2 3 4 # 1 2 3 4                     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 Info       Submit Your Request Please check all of your information before submitting.