PENTAGON CARR
Insurance Brokers
Courtiers d'assurance Inc.

Bus: 613-837-1060
Fax: 613-837-6556

3009 boul. St-Joseph Blvd.
Orléans, Ontario, K1E 1E1

Email:

Automobile Quote _______________________________

 

 

AUTOMOBILE QUOTE

DRIVER #

1.

Name
2.

Address

City

Province

Postal Code

Telephone





3.
Date of birth
Day: Month: Year:
4.
Class of current license
5.
Duration of current license
6.
Date first licensed
Day: Month: Year:
7.
Driver Training Course w/Certificate taken
8.
Number of minor convictions in last 3 years
9.
Number of major or serious convictions in last 3 years
10.
Number of at-fault, chargeable claims in last 6 years
(if any, give dates)
11.
Expiry date of current automobile insurance
Day: Month: Year:
12.
Number of consecutive years of coverage under any automobile policy
13.
Has any automobile policy been cancelled by the Insurance Company
(if yes, please give reason)

(repeat as necessary for number of drivers to be insured)

 
VEHICLE#
14.

Year

Make

Model of vehicle to insure



15.
 Two or four - door
16.
 Coverage required
17.
 Used to commute to work or school
18.
 If yes, how many kilometers in one direction?
km
19.
 Number of kilometers driven annually
km

(repeat as necessary for number of drivers to be insured)

 

Did you know that combining automobile insurance with residential insurance may result in discounts that will reduce your annual premium?

Please note that the quotation generated will be based on the information provided above. All information is subject to verification, the results of which may cause the amounts to change.

 

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