Auto Insurance

Fields marked by an asterisk (*) are required fields.
CONTACT INFORMATION
Privacy Consent: By completing this form, you are giving us permission to use your information for the purpose of providing an insurance quote,
council or risk management service. Please read our Privacy Statement for more information.

Your Name *
Address *
City (Ontario Residents Only) *
Postal Code *
Home Number
Business Phone Number
Cell Number
Fax Number
Email Address  *
How many consecutive years have you had insurance in Canada or the US? *
Current Insurer enter 'None' if no current insurance *
If no current insurance, what is the reason?
Expiry Date/Date Insurance Required *
What is your current annual premium?
Do you presently have home insurance?
Why are you looking for a new insurer or broker?
How did you hear about us?
Additional Comments
DRIVER ONE INFORMATION
Date of Birth  *
Gender *
Marital Status *
Date G, G2, and/or G1 Licence Obtained *
G Licence Date
G2 Licence Date
G1 Licence Date
Do you have a driver's training certificate? *
Have you had insurance coverage cancelled by an insurance company in the last 3 years?  *
How many traffic tickets (not parking tickets) have you had in the last 3 years?  *
How many claims have you had in the past 6 years? *
Details of claims and/or convictions if any. Include date, description, and amount paid out (for claims).
DRIVER TWO INFORMATION
Date of Birth
Gender
Marital Status
Date G Licence Obtained
Date G2 Licence Obtained
Date G1 Licence Obtained
Do you have a driver's training certificate?
Have you had insurance coverage cancelled by an insurance company in the last 3 years?
How many traffic tickets (not parking tickets) have you had in the last 3 years?
How many claims have you had in the past 6 years?
Details of claims and/or convictions if any. Include date, description, and amount paid out (for claims).
VEHICLE ONE INFORMATION
Year *
Make *
Model (please be specific) *
Use of Vehicle
Estimated Annual Kilometres *
Number of kilometres to work one way *
Third Party Liability (choose a limit)  *
Collision (choose a deductible)
Comprehensive (choose a deductible)
VEHICLE TWO INFORMATION
Year
Make
Model (please be specific)
Use of Vehicle
Estimated Annual Kilometres
Number of kilometres to work one way
Third Party Liability (choose a limit)
Collision (choose a deductible)
Comprehensive (choose a deductible)

Address: 501-1500 Don Mills Rd., Toronto, ON, M3B 3K4    Email: info@aibrokers.ca   
Phone: 1-877-213-4545 or 416-484-4545   Fax: 416-900-0322   24-Hour Claims Service: 1-888-235-2447

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