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Personal Auto Insurance

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Personal Auto Insurance

Step 1 of 5 – Applicant

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Applicant

Personal Auto Insurance

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Vehicle

AUTO

Year(Required)

Make(Required)

Model(Required)

Purchase Condition(Required)

Used

New

Date of Purchase(Required)

MM slash DD slash YYYY

Vehicle is owned, leased or financed?

Owned

Leased

Financed

Parking at night(Required)

Carport

Parking Lot

Private Driveway

Private Garage

Secure Condo/Apt Garage

Storage

Street

Underground Parking

Unsecured Condo/Apt Garage

Other

Anti-theft device installed?

Yes

No

Winter tires installed?

Yes

No

Primary use for this vehicle?(Required)

Business (examples include Realtors, Consultants, Sales)

Pleasure

Daily work commute

Distance driven annually?(Required)

Less than 8,000 kms

8,000 kms – 16,000 kms

16,000 kms – 24,000 kms

More than 24,000 kms

Daily commute (one-way)(Required)

Business use (%)(Required)

Please enter a number from 0 to 100.

Drive for compensation?

Covers carpooling, like driving coworkers to job sites, and business use like nurses or PSWs transporting patients. Does not include rideshare services like Uber or Lyft.

Yes

No

Would you like to add an additional vehicle?(Required)

Yes

No

Vehicle

AUTO

Year

Make

Model

Purchase Condition(Required)

Used

New

Date of Purchase(Required)

MM slash DD slash YYYY

Vehicle is owned, leased or financed?

Owned

Leased

Financed

Parking at night(Required)

Carport

Parking Lot

Private Driveway

Private Garage

Secure Condo/Apt Garage

Storage

Street

Underground Parking

Unsecured Condo/Apt Garage

Other

Anti-theft device installed?

Yes

No

Winter tires installed?

Yes

No

Primary use for this vehicle?

Business (examples include Realtors, Consultants, Sales)

Pleasure

Daily work commute

Distance driven annually?(Required)

Less than 8,000 kms

8,000 kms – 16,000 kms

16,000 kms – 24,000 kms

More than 24,000 kms

Distance driven one way?(Required)

Business use (%)(Required)

Please enter a number from 0 to 100.

Drive for compensation?

Covers carpooling, like driving coworkers to job sites, and business use like nurses or PSWs transporting patients. Does not include rideshare services like Uber or Lyft.

Yes

No

Would you like to add an additional vehicle?

Yes

No

Driver

PRIMARY DRIVER

Name on driver’s license(Required)

Date of birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Unspecified

Marital Status(Required)

Common-law

Married

Single

Widowed

Driver's license number(Required)

License class

G Licensed Date?

Date

MM slash DD slash YYYY

G2 Licensed Date?

Date

MM slash DD slash YYYY

G1 Licensed Date?

Date

MM slash DD slash YYYY

Minor convictions in last 3 years(Required)

At fault collisions in last 9 years(Required)

Email(Required)

Phone Number(Required)

Would you like to add another driver?

Yes

No

Driver

PRIMARY DRIVER

Name on driver’s license(Required)

Date of birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Unspecified

Marital Status(Required)

Common-law

Married

Single

Widowed

Driver's license number(Required)

License class

G Licensed Date?

Date

MM slash DD slash YYYY

(Required)

G2 Licensed Date?

Date

MM slash DD slash YYYY

(Required)

G1 Licensed Date?

Date

MM slash DD slash YYYY

Minor convictions in last 3 years(Required)

At fault collisions in last 9 years(Required)

Email(Required)

Phone Number(Required)

Would you like to add another driver?

Yes

No

Δ

1939 Ironoak Way
Suite 205
Oakville ON, L6H 3V8

905-864-0057 insure@sterlingibl.com

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