Madan Insurance Brokers
A Division of Award Insurance Brokers
AUTO / MOTORCYCLE QUOTE
AVAILABLE TO ONTARIO RESIDENTS ONLY

General information
 
    Name: 

    Street: 

    Apt#: 

    City: 

    Prov: 

    Postal Code: 

    Phone#: 

    Fax#: 

    E-mail: 

 Vehicle 1 Description

 
Model Year: 

Make: 

Model: 

Body Style: 

Cylinders or C.C.'s: 

Vehicle Use: 
Pleasure 
Business 
Farm 
Commercial 

How far do you drive one way to work? km 

Estimated annual driving distance? 
km 
 
For Motorcycle Quote ONLY:
Date first licensed to ride a motorcycle in Canada: yy/mm/dd 

Do you have Approved Motorcycle   Training:  Yes No 

Are you a GWRRA member: Yes No
List Price New: 

Current Value: 

If unknown, please provide estimate:

 


If there are no other vehicles to insure, click HERE to skip to the next section.


 Vehicle 2 Description
 
Model Year: 

Make: 

Model: 

Body Style: 

Cylinders or C.C.'s: 

Vehicle Use: 
Pleasure 
Business 
Farm 
Commercial 

How far do you drive one way to work? km 

Estimated annual driving distance? 
km 
 
For Motorcycle Quote ONLY:
Date first licensed to ride a motorcycle in Canada: yy/mm/dd 

Do you have Approved Motorcycle   Training:  Yes No 

Are you a GWRRA member: Yes No

List Price New: 

Current Value: 

If unknown, please provide estimate:

 


If there are no other vehicles to insure, click HERE to skip to the next section.


Vehicle 3 Description
 
3 Model Year: 

Make: 

Model: 

Body Style: 

Cylinders or C.C.'s: 

Vehicle Use: 
Pleasure 
Business 
Farm 
Commercial 

How far do you drive one way to work? km 

Estimated annual driving distance? 
km 
 
For Motorcycle Quote ONLY:
Date first licensed to ride a motorcycle in Canada: yy/mm/dd 

Do you have Approved Motorcycle   Training:  Yes No 

Are you a GWRRA member: Yes No

List Price New: 

Current Value: 

If unknown, please provide estimate:

 
 PrincipalDriver Information
 
     Name of principal driver? 

    Date of Birth? 
    yy/mm/dd 

    Sex: 
    Male 
    Female 

    Marital Status: 
    Single 
    Married 

    Do you have a Drivers Education Certificate: 
    Yes No 
    Date first licensed in Canada: 
    yy/mm/dd 

    Have there been any lapses or suspensions on your license in the past six years: 
    Yes No 

    Have you had any claims on any auto insurance policy in the past 6 years: 
    Yes No 

    Have you had any moving traffic violations in the past three years: 
    Yes No 

    If you answered Yes to any of the above,
    Please provide exact dates and specific details. 
    (How many kms over the speed limit, etc.)


If there are no other drivers in your household or business, click HERE to skip to next section.

 SecondDriver Information
 
Name of  driver? 

Date of Birth? 
yy/mm/dd 

Sex: 
Male 
Female 

Marital Status: 
Single 
Married 

 Do you have a Drivers Education Certificate: 
Yes No 
    Date first licensed in Canada: 
    yy/mm/dd 

    Have there been any lapses or suspensions on your license in the past six years: 
    Yes No 

    Have you had any claims on any auto insurance policy in the past 6 years: 
    Yes No 

    Have you had any moving traffic violations in the past three years: 
    Yes No 

    If you answered Yes to any of the above,
    Please provide exact dates and specific details. 
    (How many kms over the speed limit, etc.)


If there are no other drivers in your household or business, click HERE to skip to next section.


Third Driver Information
 
Name of  driver? 

Date of Birth? 
yy/mm/dd 

Sex: 
Male 
Female 

Marital Status: 
Single 
Married 

Do you have a Drivers Education Certificate: 
Yes No 
    Date first licensed in Canada: 
    yy/mm/dd 

    Have there been any lapses or suspensions on your license in the past six years: 
    Yes No 

    Have you had any claims on any auto insurance policy in the past 6 years: 
    Yes No 

    Have you had any moving traffic violations in the past three years: 
    Yes No 

    If you answered Yes to any of the above,
    Please provide exact dates and specific details. 
    (How many kms over the speed limit, etc.)
Driving History

Information for All Drivers

Any claims in the last 6 years? yes no

Any at fault claims in the last 6 years? yes no

If yes, when?


Any traffic violations in the past 3 years? yes no

If yes, for what and when? Please Explain.


Any automobile criminal convictions? (ie. DUI, etc) yes no

If yes, please explain.


Have any of the drivers had any license suspensions in the past 6 years? yes no

If yes, what was the length of the suspension? Please Explain.


Desired Coverage

Desired Coverages for Vehicle 1(Enter nil if not required):
Liability limit: Collision Deductible
Comprehensive Deductible

Desired Coverages for vehicle 2 (Enter nil if not required):
Liability limit: Collision Deductible
Comprehensive Deductible

Desired Coverage

Desired Coverages for Vehicle 3(Enter nil if not required):
Liability limit: Collision Deductible
Comprehensive Deductible

COMMENTS

Any other information which you feel may be of importance or further questions, please enter in the space below.


  This site created and maintained by:Randolph Mendonca