Blair Insurance Brokers


	Fast Quote: (905) 472-0774 176 Bullock Drive, Unit #1 Markham, Ontario L3P 1W2

AUTO QUOTE

Please complete for each vehicle and driver in the household.

Name:
Address:
City:
Postal Code:
Phone:
Email:
Number of vehicles on the policy:
Number of drivers on the policy:
Year:
Make:
Model:
How is the vehicle being used:
Number of KM one way to work:
Date of birth (mm/dd/yyyy):
Gender:
Marital status:
License class:
Date first "G" licenced (mm/dd/yyyy):
Number of years continuous prior insurance:
How many claims, not involving accidents have you had in the past 10 years:
How many accidents have you had in the last 10 years:
How many moving violations in the last 3 years:
Licence suspended in the last 6 years:
Coverage cancelled in the last 6 years:
Has your licence ever been suspended:
Liability:
Collison:
Comprehensive:
Loss of use - OPCF 20:
Family protection - OPCF 44:
Non-Owned auto - OPCF 27:
Waiver of depreciation - OPCF 43:
Deletion of glass coverage - OPCF 13c:
Are you retired:
Do you have an anti-theft device: