Step 1 of 3 33% GENERAL INFORMATIONCompany Name* Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email* Daytime Phone*Business Type* Ref by:* POLICY INFORMATIONDo you have a current commercial auto policy?* Yes No Date* MM slash DD slash YYYY Name of Current or Most Recent Insurer* Policy Renewal Date or Date Last Insured* MM slash DD slash YYYY Policy cancelled in the last 3 years? Yes No If yes, state reason and date:* VEHICLE #1 INFORMATIONRegistered Name for Vehicle* Type:* Personal Name Company Name Year*Make* Model* Body Type*Please Select One2-DoorConvertible4-DoorStation WagonPickupVanOtherIf Other, Please Specify:* Date of Vehicle Purchase*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920VIN #:* Weight of Vehicle* More than 4500kg Less than 4500kg List Price New* Is Vehicle:* Owned Leased Any Business in U.S.?* Yes No Percentage of use in U.S.*Please Describe Main Usage for Vehicle*Liability Limit*Please select one$1,000,000$2,000,000Collision Deductible*Please Select One$300$500$1,000$2,500$5,000Comprehensive Deductible*Please Select One$300$500$1,000$2,000$5,000Loss of Use:* Yes No Limited Waiver of Depreciation* Yes No Legal Liability For Non-Owned Vehicles* Yes No List Machinery & Equipment:Description* Year Manufactured*Value* Description: Year ManufacturedValue Description: Year ManufacturedValue Haul any trailers?* Yes No Use of Trailer Trailer Type Trailer YearTrailer Make Trailer Model Trailer Value Please list the merchandise carried:Are goods carried for compensation?* Yes No If yes, is there a contract in place?* Yes No Hauling for others?* Never Daily Weekly If yes, is there a contract in place?* Yes No Radius of Operations:Normal Radius: Distance one way (kms):*% of total trips:*Maximum Radius: Distance one way (kms):*% of total trips:*Number of trips per month outside of radius:*Destinations Travelled to: (Cities, Provinces)*Garaged Location of Vehicle* Have second vehicle? Yes No VEHICLE #2 INFORMATIONRegistered Name for Vehicle* Type:* Personal Name Company Name Year*Make* Model* Body Type*Please Select One2-DoorConvertible4-DoorStation WagonPickupVanOtherIf Other, Please Specify:* Date of Vehicle Purchase*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920VIN #:* Weight of Vehicle* More than 4500kg Less than 4500kg List Price New* Is Vehicle:* Owned Leased Any Business in U.S.?* Yes No Percentage of use in U.S.*Please Describe Main Usage for Vehicle*Liability Limit*Please select one$1,000,000$2,000,000Collision Deductible*Please Select One$300$500$1,000$2,500$5,000Comprehensive Deductible*Please Select One$300$500$1,000$2,000$5,000Loss of Use:* Yes No Limited Waiver of Depreciation* Yes No Legal Liability For Non-Owned Vehicles* Yes No List Machinery & Equipment:Description:* Year Manufactured*Value:* Description: Year ManufacturedValue: Description: Year ManufacturedValue: Haul any trailers?* Yes No Use of Trailer Trailer Type Trailer YearTrailer Make Trailer Model Trailer Value Please list the merchandise carried:Are goods carried for compensation?* Yes No If yes, is there a contract in place?* Yes No Hauling for others?* Never Daily Weekly If yes, is there a contract in place?* Yes No Radius of Operations:Normal Radius: Distance one way (kms):*% of total trips:*Maximum Radius: Distance one way (kms):*% of total trips:*Number of trips per month outside of radius:*Destinations Travelled to: (Cities, Provinces)*Garaged Location of Vehicle* Have third vehicle? Yes No VEHICLE #3 INFORMATIONRegistered Name for Vehicle* Type:* Personal Name Company Name Year*Make* Model* Body Type*Please Select One2-DoorConvertible4-DoorStation WagonPickupVanOtherIf Other, Please Specify:* Date of Vehicle Purchase*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920VIN #:* Weight of Vehicle* More than 4500kg Less than 4500kg List Price New* Is Vehicle:* Owned Leased Any Business in U.S.?* Yes No Percentage of use in U.S.*Please Describe Main Usage for Vehicle*Liability Limit*Please select one$1,000,000$2,000,000Collision Deductible*Please Select One$300$500$1,000$2,500$5,000Comprehensive Deductible*Please Select One$300$500$1,000$2,000$5,000Loss of Use:* Yes No Limited Waiver of Depreciation* Yes No Legal Liability For Non-Owned Vehicles* Yes No List Machinery & Equipment:Description:* Year Manufactured*Value:* Description: Year ManufacturedValueDescription: Year ManufacturedValue: Haul any trailers?* Yes No Use of Trailer Trailer Type Trailer YearTrailer Make Trailer Model Trailer ValuePlease list the merchandise carried:Are goods carried for compensation?* Yes No If yes, is there a contract in place?* Yes No Hauling for others?* Never Daily Weekly If yes, is there a contract in place?* Yes No Radius of Operations:Normal Radius: Distance one way (kms):*% of total trips:*Maximum Radius: Distance one way (kms):*% of total trips:*Number of trips per month outside of radius:*Destinations Travelled to: (Cities, Provinces)*Garaged Location of Vehicle* DRIVER #1 INFORMATIONName First Last AgeGender Male Female Prefer Not to Answer Drives Which Vehicle?Please select all that apply. Vehicle #1 Vehicle #2 Vehicle #3 Percentage of use of this vehicle:How long licensed?Previous Commercial ExperiencePlease Select OneNone1 Year2 Years3 Years4 Years5 Years6 YearsMore than 6 YearsNumber of years experienced driving listed vehicle or similar type of vehicleDrivers License No. License Expiry Date Year Month Day License Dates: All fields below are required. If not applicable, please indicate N/A. G (yyyy/mm) G1 (yyyy/mm) G2 (yyyy/mm) A (yyyy/mm) AZ (yyyy/mm) Other Class Type & Date (yyyy/mm) Approved Driver's Training Yes No Consecutively insured for:Please Select OneNone1 Year2 Years3 Years4 Years5 Years6 Years7+ YearsMinor Convictions in the past 3 years: Yes No If yes, provide dates and types:Major Violations in the past 3 years: Yes No If yes, provide dates and types:Claims in the past 3 years: Yes No If yes, provide details on all claims (collision, comprehensive and glass claims):License Suspension in the past 6 years: Yes No If yes, provide details why your license was suspended, date of the suspension and date of reinstatement:Cancellations for Non-Payment in the past 6 years: Yes No If yes, provide details when cancelled and dates:Add second driver? Yes No DRIVER #2 INFORMATIONName First Last AgeGender Male Female Prefer Not to Answer Drives Which Vehicle?Please select all that apply. Vehicle #1 Vehicle #2 Vehicle #3 Percentage of use of this vehicle:How long licensed?Previous Commercial ExperiencePlease Select OneNone1 Year2 Years3 Years4 Years5 Years6 YearsMore than 6 YearsNumber of years experienced driving listed vehicle or similar type of vehicleDrivers License No. License Expiry Date Year Month Day License Dates: All fields below are required. If not applicable, please indicate N/A. G (yyyy/mm) G1 (yyyy/mm) G2 (yyyy/mm) A (yyyy/mm) AZ (yyyy/mm) Other Class Type & Date (yyyy/mm) Approved Driver's Training Yes No Consecutively insured for:Please Select OneNone1 Year2 Years3 Years4 Years5 Years6 Years7+ YearsMinor Convictions in the past 3 years: Yes No If yes, provide dates and types:Major Violations in the past 3 years: Yes No If yes, provide dates and types:Claims in the past 3 years: Yes No If yes, provide details on all claims (collision, comprehensive and glass claims):License Suspension in the past 6 years: Yes No If yes, provide details why your license was suspended, date of the suspension and date of reinstatement:Cancellations for Non-Payment in the past 6 years: Yes No If yes, provide details when cancelled and dates:Add Third Driver? Yes No DRIVER #3 INFORMATIONName First Last AgeGender Male Female Prefer Not to Answer Drives Which Vehicle?Please select all that apply. Vehicle #1 Vehicle #2 Vehicle #3 Percentage of use of this vehicle:How long licensed?Previous Commercial ExperiencePlease Select OneNone1 Year2 Years3 Years4 Years5 Years6 YearsMore than 6 YearsNumber of years experienced driving listed vehicle or similar type of vehicleDrivers License No. License Expiry Date Year Month Day License Dates: All fields below are required. If not applicable, please indicate N/A. G (yyyy/mm) G1 (yyyy/mm) G2 (yyyy/mm) A (yyyy/mm) AZ (yyyy/mm) Other Class Type & Date (yyyy/mm) Approved Driver's Training Yes No Consecutively insured for:Please Select OneNone1 Year2 Years3 Years4 Years5 Years6 Years7+ YearsMinor Convictions in the past 3 years: Yes No If yes, provide dates and types:Major Convictions in the past 3 years: Yes No If yes, provide dates and types:Claims in the past 3 years: Yes No If yes, provide details on all claims (collision, comprehensive and glass claims):License Suspension in the past 6 years: Yes No If yes, provide details why your license was suspended, date of the suspension and date of reinstatement:Cancellations for Non-Payment in the past 6 years: Yes No If yes, provide details when cancelled and dates:Additional Comments/InformationNameThis field is for validation purposes and should be left unchanged.
