7 William Street, Unit #2
Parry Sound, Ontario
CANADA
P2A 1V2
Tel: (705) 746-2725
Fax: (705) 746-6420

Quotation for Automobile
If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: psinsure@zeuter.com
Important: Please be accurate in completing this form. Your quotation will be based on the information you give us today. If these facts change, your rate will be subject to adjustment.
Information requested below is used by this brokerage to develop a prospect profile, and may or may not be used in the pricing of any estimated policy premiums.

Personal Information
First Name:
Last Name:
E-Mail:
Address:
City/Town:
Province:
Postal Code:
Home Telephone:
Business Telephone:
Fax Number:
Occupation:
Vehicle Information
Registered Owner:
First Name
Last name
Year:
Make:
Model:
Body: (2 dr. etc.)
2WD or 4WD? 2WD 4WD
Vehicle Usage Information
Annual Kilometres: (expected this year)
Daily Km. one way
Anti-Theft Device? Yes No
If you take your vehicleout of the country for extended periods of time with you, please show number of months:
Check the boxes following to indicate use of vehicle:
Pleasure
Business
Commute
If you selected "business" please describe the type of business and any cargo carried.
Current Policy Information
Insurance Company:
Policy Number:
Policy Expiry Date:
Driver Information
Driver's licence numbers may be significant to the underwriting accuracy and will speed the return of your quote.
Driver's First Name:
Last Name:
Driver's Licence Number:
Relation to Applicant:
Date of Birth:
Sex: Female Male
Date First Licenced in Canada?
Occupation:
Married? YesNo
Driver Training? YesNo
Do you hold a current license valid in another country? YesNo
Indicate # of years each driver has been licenced
Driver 1 :
Driver 2 :
Indicate if driver has had insurance cancelled and for what reason:
Nonpayment
Fraud
Misrepresentation
Claims Information
Any claims or accidents in the last 6 years?
Any convictions, fines or traffic violations in the last 3 years?
Any losses due to theft, vandalism or other comprehensive claims in the last 6 years?
Any licence suspensions in the past 6 years?
If none of the 4 boxes above are checked please skip the following sections.
List the two most recent claims or accidents in the past six years.
Claim 1
Date:
Was this driver at fault? YesNo
Did your insurance company pay out on the claim? YesNo
If yes, how much was paid out on the claim (if known)?
Own car:
Other car:
List details of accident
Claim 2
Date:
Was this driver at fault? YesNo
Did your insurance company pay out on the claim? YesNo
If yes, how much was paid out on the claim (if known)?
Own car:
Other car:
List details of accident
Are there more than two claims? No Yes.
If you checked yes please list details of all claims in the last six years
List losses due to theft, vandalism or other comprehensive claims in the past 6 years.
List convictions, fines for traffic violations in the past 3 years.
State if driver's licence has been suspended or revoked in the past 6 years.
Coverage Required
Mandatory Coverage Liability - Please select the amount.
Vehicle 1

Vehicle 2
Statutory Coverage:
  1. Accident Benefits
  2. Family Protection Endorsement
Loss or Damage Deductible - Please select the amount. Comprehensive (excluding Collision or Upset)
Collision or Upset
Do you require coverage for Loss of Use?
Please recheck to make sure you have supplied all information requested. Please make sure each section in filled, so that all your applicable discounts can be determined.




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Parry Sound Insurance Brokers Ltd., 7 William Street, Unit #2, Parry Sound, Ontario, CANADA P2A 1V2
tel: (705) 746-2725 * fax: (705) 746-6420 * email: psinsure@zeuter.com

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Box 225, Parry Sound, Ontario, CANADA P2A 2X3 Tel/FAX (705)746-4625
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