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Personal Auto Insurance
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Personal Auto Insurance
Step
1
of
5
– Applicant
0%
Applicant
Personal Auto Insurance
Name
(Required)
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
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