Tupling Insurance Brokers Limited
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QUOTE REQUESTS
Car Insurance
Branch:
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Have you ever had insurance cancelled, refused or non–renewed??
Yes     No
Do you currently insure your vehicle(s)?
Yes     No
If not, have you had insurance for 12 consecutive months within the last 10 years?
Yes     No
When should coverage start? (dd/mm/yyyy)
List all driver(s) in household:
#1 #2 #3
Name:
Date of Birth:
Drivers License #:
Date G1 licensed:
Date G2 licensed:
Date G licensed:
License class:
Sex:
Marital status:
Do you hold a MTO approved driver training certificate?
Retired?
Minor traffic convictions
in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
Are you currently insured?
Yes     No
Name of current or most recent Insurance Company:
Have any of above drivers had their licenses suspended or lapsed in the past 6 years?
Yes     No
Have any of the drivers above
had accidents or claims
in the past 10 years?
Yes     No
Claims Information:
Claims Date (mm/yyyy) Driver
involved
#1:
#2:
#3:
   
Vehicle Information:
Vehicle #1 Vehicle #2
Vehicle make:
Year:
Make and Model:
Style:
Use:
KM driven one way to work:
Kilometres driven per year:
Who is primary driver:
   
Coverage Required:
Vehicle #1 Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:
 

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