Car Insurance Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 2Full name of owner of the car *FirstLastDate of birthDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderMaleFemaleAddressAddress Line 1CityState / Province / RegionPostal CodePhone Number *Email *Occupation / Job title *Would you agree to a soft credit check (no impact to your score) to provide you with the most accurate and competitve insurance quote? *YesNoDo you have a criminal file? *YesNoHave you ever declared bankruptcy or a consumer proposal? *YesNoIs this your first car insurance in Quebec? *YesNoWhat is the name of your current car insurance company *When does your current car insurance contract expire?DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Quebec Driver’s License Number * file? Would current How many years of driving experience do you have? *Do you authorize me to verify your accident record under your driver’s license? *YesNoNextYear, Make and Model of the Car *Serial number (VIN) of the car *Amount Paid or Value of the Car Before TaxesCar purchase or lease date *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the car paid in full, leased, or financed? *Paid in FullLeasedFinancedIs there anyone else other than yourself who will be driving the car on a regular basis? (Leave empty if none) *How many kilometers do you drive annually? *Has your driver’s license ever been suspended? *YesNoHave you ever had any claims/accidents? *YesNoHave you ever been canceled for non-payment of a premium? *YesNoWill the car be used for Uber Passenger or regular taxi activity? *YesNoWill the car be used for any Uber Eats or food/package delivery? *YesNoIs there a TAG anti-theft system installed on the car (extra discount)? *YesNoIs there any usage outside of Quebec for more than 30 days per year? *YesNoSubmit
