Name: *
Email Address: *
Phone Number: *
Address: *
City: *
Province: *
Postal Code: *
Name of Principal Operator: *
Date of Birth: *
Marital status: married single *
Name of Spouse:
Date of Birth of Spouse:
Number of child(ren) who are licensed drivers: *
Name of child #1:
Date of Birth #1:
Number of years licensed for driver #1:
Name of child #2:
Date of Birth #2:
Number of years licensed for driver #2:
Any driving convictions in the past 3 years?: Yes No *
Value of Recreational Vehicle: *
Number of CC's: *
List Price New: *
Any at fault accidents in the past 6 years?: Yes No *
Liability limit requested: $1,000,000 $2,000,000 $5,000,000 *
Coverage Preferred: All Perils Collision Comprehensive Specified Perils *
Deductible: $100 $250 $500 $1000 *
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