Enter your email address here:  *    Enter your real name here: *
In what province do you live and work? Nova ScotiaNew Brunswick*  What is your postal code? *
What is the renewal date of current insurance: *
If not currently insured, when was the last time you had insurance?  
When did you first get your license? 
Have you been insured continuously for at least the last 6 years? YESNO *
Have you ever had your insurance cancelled for non-payment? YESNO*  If yes, when? 
PRINCIPAL OPERATOR INFORMATION
The Principal Operator of the vehicle is: *
How long has the Principal Operator been licensed?* Years	
Are you the only driver of the automobile? YESNO *  If No, then please complete the following section on Additional Drivers.
Names of other people in the household with a driving license, their relationship to you, how long they have had a license.
1)  Licensed fewer that 9 Years? YESNO 
2) Licensed fewer than 9 Years? YESNO
Are there more than 2 other drivers? YESNO  (Yes/No)     If yes, provide details in comments section below.



VEHICLE INFORMATION

Year, Make, Model of vehicle (Exact details required, including VIN if available)) * 
(Describe additional vehicles in the comment section at the bottom.





COVERAGES

Enter amount of PLPD (Third Party Liability) required. 
$200,000$500,000$1,000,000
* (Minimum $200,000 in N.B. and $500,000 in N.S. We recommend $1,000,000)


Enter amount of Deductible if Collision coverage is required 
$100$250$500


Enter amount of Deductible if Comprehensive coverage is required. 
$100$250$500 


Are other coverages (All Perils, Specified Perils) required?




CLAIMS/ACCIDENTS/CONVICTIONS
Have you or any driver ever had your license suspended or cancelled? YESNO* 
Has there ever been a claim on a vehicle or insurance policy by you or any driver?YESNO (If yes, please provide month, year, type of claim, amount of claim in comments section below.)
Has any driver ever had a motor vehicle or criminal code conviction? YESNO* If yes, provide month, year, and details of the conviction in comments section below.)
Does any driver have a medical or physical condition which might impair the safe operation of a vehicle? YESNO*

VEHICLE USE
Is the vehicle driven to/from work? YESNO  * If yes, how many km to work one way?  km
Is the vehicle used in any business or commercial enterprise? YESNO*  If yes, explain. 
COMMENTS / ADDITIONAL INFORMATION
Ask any questions or provide additional details in the space below:
     
		 
		

		
		
		
		
		
 		

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		information about automobile insurance click here.