Car Information :
Make:
Model:
Year:
New/Used: New
Used
Principal Driver Information :
Age:
Sex: Male
Female
Status: Married
Single
Primary Usage: Pleasure Only
Commuting to & from work
Business
Commercial
Distance to Work: Kms
Years Driving: Yrs
Annual Mileage: Kms
Driver Training Courses Completed:
Accident & Claim History (last 6 yrs):
Convictions & Moving Violations (last 6 yrs):
Suspension of Driver Licence for any Driver:
Previous Insurer, Policy Number & Expiry Date:
Occasional Driver Information :
Age:
Sex: Male
Female
Status: Married
Single
Primary Usage: Pleasure Only
Commuting to & from work
Business
Commercial
Distance to Work: Kms
Years Driving: Yrs
Annual Mileage: Kms
Driver Training Courses Completed:
Accident & Claim History (last 6 yrs):
Convictions & Moving Violations (last 6 yrs):
Suspension of Driver Licence for any Driver:
Previous Insurer, Policy Number & Expiry Date:
Coverage Required: Liability:
$500,000 $1,000,000

Accident Benefits

Collison Deductible:
$300 Higher Deductible

Comprehensive:
$100 Higher Deductible

Loss of Use

Family Protection

Depreciation Waiver
Region: Avalon
Central
Western
Personal Information :
Name :
Telephone :
Email Address: