SUBMIT
PERSONAL AUTOMOBILE QUESTIONNAIRE
PART 1
GENERAL INFORMATION
How did you hear about Insight?
Applicants Full Name
Address Including Postal Code
Occupation
Consent
Email
Yes
No
CO APPLICANT’S FULL NAME
In respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may order personal information reports including policy
history, claims history, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by
law. Do you, and on behalf of others listed, authorize us to collect, use and disclose to appropriate third parties, this information solely relating to your personal
property policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate
and settle claims, analyze business results and detect and prevent fraud?
Consent
Date Of Birth
Relationship to Applicant
Yes
No
Occupation
PRESENT INSURANCE INFORMATION:
Current Carrier
Policy #
Expiration Date
PART 2
Current Premium
DRIVERS
Date of Birth
DRIVER #1: NAME:
Marital Status:
Single
Driver Training:
Married
Yes
Common Law
No
Other
N/A
Continuous Insurance Since
Current Insurer:
How Long Insured With?
Convictions? (3Yrs)
Acciden ts? (6Yrs)
If yes, list dates and type:
Suspension?
Yes
No
Gaps In Ins?
No
Yes
If Yes, Please Explain
Date of Birth
DRIVER #2: NAME:
Marital Status:
Single
Driver Training:
Married
Yes
Common Law
No
Other
N/A
Continuous Insurance Since
Current Insurer:
How Long Insured With?
Convictions?(3Yrs)
Acciden ts? (6Yrs)
If yes, list dates and type:
Suspension?
Yes
No
Gaps In Ins?
Yes
No
If Yes, Please Explain
[email protected] | t: 780.455.3412 | f: 780.455.3419
PAGE 1 OF 3
SUBMIT
DRIVER #3: NAME:
Date of Birth
Marital Status:
Single
Driver Training:
Married
Yes
Common Law
No
Other
N/A
Continuous Insurance Since
Current Insurer:
How Long Insured With?
Convictions?(3Yrs)
Acciden ts? (6Yrs)
If yes, list dates and type:
Suspension?
No
Yes
Gaps In Ins?
Yes
No
If Yes, Please Explain
PART 3
AUTOMOBILES
Auto #1: PRIMARY DRIVER
Year
Make
Model
VIN
Is there a lienholder or lessor?
Yes
NEW
USED
NEW
USED
No
Please Check One?
Pleasure Use Only (No Commuting)
How many kilometres/year?
Commute
How many kilometres/year?
Business Use
How many kilometres/year?
Coverage Requested:
Auto #2: PRIMARY DRIVER
Year
Make
Model
VIN
Is there a lienholder or lessor?
Yes
No
Please Check One?
Pleasure Use Only (No Commuting)
How many kilometres/year?
Commute
How many kilometres/year?
Business Use
How many kilometres/year?
Coverage Requested:
[email protected] | t: 780.455.3412 | f: 780.455.3419
PAGE 2 OF 3
SUBMIT
Auto #3: PRIMARY DRIVER
Year
Make
Model
VIN
Is there a lienholder or lessor?
Yes
NEW
USED
No
Please Check One?
Pleasure Use Only (No Commuting)
How many kilometres/year?
Commute
How many kilometres/year?
Business Use
How many kilometres/year?
Coverage Requested:
PART 4
MISCELLANEOUS
Motorcycles #1
Year
Make
Model
Serial Number
Engine (cc)
Value ($)
Is Vehicle Used To Commute:
Yes
No
If so, how many kilometers / way?
Driver Training Completed?
Yes
No
Coverage Requested:
Motorcycles #2:
Year
Make
Model
Serial Number
Engine (cc)
Value ($)
Is Vehicle Used To Commute:
Yes
No
If so, how many kilometers / way?
Driver Training Completed?
Yes
No
Coverage Requested:
ATV/SNOWMOBILE #1:
Year
Serial Number
Make
Engine (cc)
Model
Value ($)
Coverage Requested
ATV/SNOWMOBILE #2:
Serial Number
Make
Year
Engine (cc)
Model
Value ($)
Coverage Requested
[email protected] | t: 780.455.3412 | f: 780.455.3419
PAGE 3 OF 3