Auto Quotation | 3 Drivers

Your Email Address (to receive a copy of your submission)

How did you hear about us? How did you hear about us? Referral I am a current client Media Ad Google Other

May we ask who referred you?

Driver 1

First Name

Last Name

Address

City

Postal Code

Main Phone

Ext.

Email Address

Date of birth

Marital Status

Occupation (Possible discounts)

Place of Employment

Are you currently licensed in Alberta? Are you currently licensed in Alberta? Yes No

What class of licence do you hold?

How many years have you been licensed in Alberta?

How many years have you maintained continuous insurance without any gaps in coverage greater than two years at a stretch?

Have you been licensed anywhere previous to Alberta?

What is the name of your current insurance company?

How many years have you been insured with that company?

Any traffic tickets in the past three years? Any traffic tickets in the past three years? yes no

Description and approximate date of ticket

Any accidents or claims of any kind in the past ten years? Any accidents or claims of any kind in the past ten years? yes no

Description and approximate date

In the past five years, has any insurance company cancelled your policy for missed or late payments? In the past five years, has any insurance company cancelled your policy for missed or late payments? Yes No

Have you had your licence suspended at all in the past five years? Have you had your licence suspended at all in the past five years? Yes No

Driver 2

First Name

Last Name

Main Phone

Ext.

Email Address

Date of birth

Marital Status

Occupation (Possible discounts)

Place of Employment

Are you currently licensed in Alberta? Are you currently licensed in Alberta? Yes No

What class of licence do you hold?

How many years have you been licensed in Alberta?

Have you been licensed anywhere previous to Alberta?

How many years have you maintained continuous insurance without any gaps in coverage greater than two years at a stretch?

What is the name of your current insurance company?

How many years have you been insured with that company?

Any traffic tickets in the past three years? Any traffic tickets in the past three years? yes no

Description and approximate date of ticket

Any accidents or claims of any kind in the past ten years? Any accidents or claims of any kind in the past ten years? yes no

Description and approximate date

Have you had your licence suspended at all in the past five years? Have you had your licence suspended at all in the past five years? Yes No

In the past five years, has any insurance company cancelled your policy for missed or late payments? In the past five years, has any insurance company cancelled your policy for missed or late payments? Yes No

Driver 3

First Name

Last Name

Main Phone

Ext.

Email Address

Date of birth

Marital Status

Occupation (Possible discounts)

Place of Employment

Are you currently licensed in Alberta? Are you currently licensed in Alberta? Yes No

What class of licence do you hold?

How many years have you been licensed in Alberta?

Have you been licensed anywhere previous to Alberta?

How many years have you maintained continuous insurance without any gaps in coverage greater than two years at a stretch?

What is the name of your current insurance company?

How many years have you been insured with that company?

Any traffic tickets in the past three years? Any traffic tickets in the past three years? yes no

Description and approximate date of ticket

Any accidents or claims of any kind in the past ten years? Any accidents or claims of any kind in the past ten years? yes no

Description and approximate date

Have you had your licence suspended at all in the past five years? Have you had your licence suspended at all in the past five years? Yes No

In the past five years, has any insurance company cancelled your policy for missed or late payments? In the past five years, has any insurance company cancelled your policy for missed or late payments? Yes No

Vehicle Information

How many vehicles are there to be insured? How many vehicles are there to be insured? 1 2 3

Vehicle 1

Which driver will be the primary operator of this vehicle? Which driver will be the primary operator of this vehicle? Driver 1 Driver 2 Driver 3

What is the year of the vehicle to be insured?

What is the current manufacturer (Ford, Toyota, Kia, etc.) of the vehicle to be insured?

What is the model of the vehicle to be insured?

If possible please provide the VIN for the vehicle to be insured.

Approximate vehicle purchase date?

Approximate vehicle purchase price?

Coverage

Liability Coverage Amount (what is this? Liability Coverage Amount (what is this? $2,000,000 $1,000,000

Collision Coverage Amount (what is this? Collision Coverage Amount (what is this? $1,000 Deductible $500 Deductible No coverage needed

Comprehensive Coverage Amount (what is this?) Comprehensive Coverage Amount (what is this?) $1,000 Deductible $500 Deductible No coverage needed

What will the day to day use of this vehicle be? What will the day to day use of this vehicle be? Pleasure use only. Commuting to work less than 5 KM one way. Commuting to work more than 5 KM but less than 30 KM one way. Commuting to work more than 30 KM one way or business use.

Vehicle 2

Which driver will be the primary operator of this vehicle? Which driver will be the primary operator of this vehicle? Driver 1 Driver 2 Driver 3

What is the year of the vehicle to be insured?

What is the current manufacturer (Ford, Toyota, Kia, etc.) of the vehicle to be insured?

What is the model of the vehicle to be insured?

If possible please provide the VIN for the vehicle to be insured.

Approximate vehicle purchase date?

Approximate vehicle purchase price?

Coverage

Liability Coverage Amount (what is this?) Liability Coverage Amount (what is this?) $2,000,000 $1,000,000

Collision Coverage Amount (what is this?) Collision Coverage Amount (what is this?) $1,000 Deductible $500 Deductible No coverage needed

Comprehensive Coverage Amount (what is this?) Comprehensive Coverage Amount (what is this?) $1,000 Deductible $500 Deductible No coverage needed

What will the day to day use of this vehicle be? What will the day to day use of this vehicle be? Pleasure use only. Commuting to work less than 5 KM one way. Commuting to work more than 5 KM but less than 30 KM one way. Commuting to work more than 30 KM one way or business use.

Vehicle 3

Which driver will be the primary operator of this vehicle? Which driver will be the primary operator of this vehicle? Driver 1 Driver 2 Driver 3

What is the year of the vehicle to be insured?

What is the current manufacturer (Ford, Toyota, Kia, etc.) of the vehicle to be insured?

What is the model of the vehicle to be insured?

If possible please provide the VIN for the vehicle to be insured.

Approximate vehicle purchase price?

Approximate vehicle purchase date?

Coverage

Liability Coverage Amount (what is this?) Liability Coverage Amount (what is this?) $2,000,000 $1,000,000

Collision Coverage Amount (what is this?) Collision Coverage Amount (what is this?) $1,000 Deductible $500 Deductible No coverage needed

Comprehensive Coverage Amount (what is this?) Comprehensive Coverage Amount (what is this?) $1,000 Deductible $500 Deductible No coverage needed

What will the day to day use of this vehicle be? What will the day to day use of this vehicle be? Pleasure use only. Commuting to work less than 5 KM one way. Commuting to work more than 5 KM but less than 30 KM one way. Commuting to work more than 30 KM one way or business use.

We may suggest additional coverage in our quotes

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Do you agree to the Terms & Conditions? Do you agree to the Terms & Conditions? I agree to the Touchstone Insurance Quotation Terms & Conditions