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Company Name*
Contact's First Name*
Contact's Last Name*
Address*
City*
Province*
Postal Code*
Phone Number*
Please, re-enter your Phone Number*
E-mail address
Please, re-enter your E-mail address
Preferred way to be reached
Year, make and model of Vehicle 1
Describe use of Vehicle 1
Radius of operation for Vehicle 1
Describe claims for Vehicle 1 over past 5 years
Year, make and model of Vehicle 2
Describe use of Vehicle 2
Radius of operation for Vehicle 2
Describe claims for Vehicle 2 over past 5 years
Year, make and model of Vehicle 3
Describe use of Vehicle 3
Radius of operation for Vehicle 3
Describe claims for Vehicle 3 over past 5 years
Year, make and model of Vehicle 4
Describe use of Vehicle 4
Radius of operation for Vehicle 4
Describe claims for Vehicle 4 over past 5 years
Expiry date of current Vehicle Insurance
Coverage Preferred
All Perils	No Yes
if yes, deductible
Collision	No Yes
if yes, deductible
Comprehensive	No Yes
if yes, deductible
Specified Perils	No Yes
if yes, deductible
Has any company ever cancelled or refused insurance of this description?	Yes No