*
Please note:
Auto insurance quotes are only applicable/available to Ontario drivers.
This form is also available in pdf format if you prefer not to complete the quote form online.
*REQUIRED INFORMATION
Contact Information:
*
Name:
*
Telephone:
(H)
(W)
City:
ON
*
Postal Code:
*
Email:
Drivers:
*
Number of drivers in the household:
*Including occasional under age 25 drivers
Driver 1
*
Name:
*
Date of Birth: (dd/mm/yy)
Status:
Single
Married
C/L
for
yrs
Gender:
M
F
Primary Driver of Vehicle:
1
2
3
Retired:
Yes
No
*
Date Licence Acquired: (dd/mm/yy)
Full G:
G2:
G1:
Driver Training Certificate:
Yes
No
Tickets/Violations:
*
If more than 3 tickets, please contact the office.
Date of 1st: (dd/mm/yy)
Type:
Date of 2nd: (dd/mm/yy)
Type:
Date of 3rd: (dd/mm/yy)
Type:
Claims:
*
If more than 2 claims, please contact the office.
Most Recent: (dd/mm/yy)
At Fault:
Yes
No
Date of 2nd: (dd/mm/yy)
At Fault:
Yes
No
No First Driver
">
Driver 2
Name:
Date of Birth: (dd/mm/yy)
Status:
Single
Married
C/L
for
yrs
Gender:
M
F
Primary Driver of Vehicle:
1
2
3
Retired:
Yes
No
Date Licence Acquired: (dd/mm/yy)
Full G:
G2:
G1:
Driver Training Certificate:
Yes
No
Tickets/Violations:
*
If more than 3 tickets, please contact the office.
Date of 1st: (dd/mm/yy)
Type:
Date of 2nd: (dd/mm/yy)
Type:
Date of 3rd: (dd/mm/yy)
Type:
Claims:
*
If more than 2 claims, please contact the office.
Most Recent: (dd/mm/yy)
At Fault:
Yes
No
Date of 2nd: (dd/mm/yy)
At Fault:
Yes
No
No Second Driver
">
Driver 3
Name:
Date of Birth: (dd/mm/yy)
Status:
Single
Married
C/L
for
yrs
Gender:
M
F
Primary Driver of Vehicle:
1
2
3
Retired:
Yes
No
Date Licence Acquired: (dd/mm/yy)
Full G:
G2:
G1:
Driver Training Certificate:
Yes
No
Tickets/Violations:
*
If more than 3 tickets, please contact the office.
Date of 1st: (dd/mm/yy)
Type:
Date of 2nd: (dd/mm/yy)
Type:
Date of 3rd: (dd/mm/yy)
Type:
Claims:
*
If more than 2 claims, please contact the office.
Most Recent: (dd/mm/yy)
At Fault:
Yes
No
Date of 2nd: (dd/mm/yy)
At Fault:
Yes
No
No Third Driver
">
Insurance:
*
Do you presently have insurance?
Yes
No
If yes, please enter name of present insurance company below:
Expiry Date: (dd/mm/yy)
Number of Years:
If you selected 'No' above, please enter the previous insurance information on which you were listed as a driver below:
*
Policy Number: If required later in the processing of your quote we will contact you for this.
Expiry Date: (dd/mm/yy)
Number of Years:
Have you had your automobile coverage cancelled in the last 3 years due to lack of payment?
Yes*
No
*If yes,
times
Vehicles:
*
More than one vehicle in the household:
Yes
No
Vehicle 1
If applicable, KM driven to work/school ONE way:
0
1-5
6-10
11-16
17-24
25-30
31+
Is this vehicle used for business?
Yes
No
Year:
Make:
Model:
Loss of Use:
Yes
No
Liability:
- - - - - - - - - -
$1,000,000
$2,000,000
Collision/Comprehensive:
Yes
No
Please select your deductible amounts:
Collision:
- - - - - - - - - -
$500
$750
$1,000
No Coverage
Comprehensive:
- - - - - - - - - -
$300
$500
$750
No Coverage
All Perils:
Yes
No
Please select your deductible amount:
All Perils:
- - - - - - - - - -
$500
$750
$1,000
No Coverage
No Insurance on the vehicle:
True
No First Vehicle
">
Vehicle 2
If applicable, KM driven to work/school ONE way:
0
1-5
6-10
11-16
17-24
25-30
31+
Is this vehicle used for business?
Yes
No
Year:
Make:
Model:
Loss of Use:
Yes
No
Liability:
- - - - - - - - - -
$1,000,000
$2,000,000
Collision/Comprehensive:
Yes
No
Please select your deductible amounts:
Collision:
- - - - - - - - - -
$500
$750
$1,000
No Coverage
Comprehensive:
- - - - - - - - - -
$300
$500
$750
No Coverage
All Perils:
Yes
No
Please select your deductible amount:
All Perils:
- - - - - - - - - -
$500
$750
$1,000
No Coverage
No Insurance on the vehicle:
True
No Second Vehicle
">
Vehicle 3
If applicable, KM driven to work/school ONE way:
0
1-5
6-10
11-16
17-24
25-30
31+
Is this vehicle used for business?
Yes
No
Year:
Make:
Model:
Loss of Use:
Yes
No
Liability:
- - - - - - - - - -
$1,000,000
$2,000,000
Collision/Comprehensive:
Yes
No
Please select your deductible amounts:
Collision:
- - - - - - - - - -
$500
$750
$1,000
No Coverage
Comprehensive:
- - - - - - - - - -
$300
$500
$750
No Coverage
All Perils:
Yes
No
Please select your deductible amount:
All Perils:
- - - - - - - - - -
$500
$750
$1,000
No Coverage
No Insurance on the vehicle:
True
No Third Vehicle
">
Additional Information:
Enter the text shown on image above
KW Insurance Brokers
O/B 1216592 ON LTD
501 Krug St. (Krug St. Plaza), Kitchener, ON N2B 1L3
Telephone: (519) 744-4190 Fax: (519) 744-7664
Website:
www.kwbroker.ca
