Conestoga Logo Conestoga Insurance Brokers Ltd
Request for Auto Insurance Quote
Ontario Residents Only!
Please provide ALL applicable information in order for us to promptly complete your request!

Applicant

Name:     E-mail:  
Address:   Postal Code:  
City:   Phone:  
Please make sure your contact information is accurate so that we can contact you!

Drivers
If Licensed after Mar 31 1994
Driver Sex Date of Birth
 Date of G License
 Date of G1 License Date of G2 License Driver Training
1 Male Female
DD/MM/YYYY
DD/MM/YYYY
MM/YYYY
MM/YYYY
2 Male Female
DD/MM/YYYY
DD/MM/YYYY
MM/YYYY
MM/YYYY
3 Male Female
DD/MM/YYYY
DD/MM/YYYY
MM/YYYY
MM/YYYY
4 Male Female
DD/MM/YYYY
DD/MM/YYYY
MM/YYYY
MM/YYYY
The G1 & G2 fields are not necessary if you received your license prior to April 1st 1994
as Graduated Licensing did not come into effect untill that time.

Vehicle Coverage Vehicle Use
Auto Year Make Model Liability Amt Collision Deductible Comp Deductible Primary Usage Occasional Drivers
1     e.g Cavalier   e.g Z24 2 Door 4 Cyl 1 2 3 4
2     e.g Cavalier   e.g Z24 2 Door 4 Cyl 1 2 3 4
3     e.g Cavalier   e.g Z24 2 Door 4 Cyl 1 2 3 4
2     e.g Cavalier   e.g Z24 2 Door 4 Cyl 1 2 3 4
For the Occastional Drivers section please select the appropriate Driver Number(s) from Drivers Section of the form!

How many years have you been insured  
If you are NOT currently insured, How many Months have you been uninsured?

Name of Current Insurance Company if any:
Renewal Date

Have you ever been cancelled for non-payment?  

Have claims been made by ANY of the drivers in the past 6 years?  
If Yes, please explain.


Do any drivers have moving traffic violations such as speeding, seatbelts, dangerous driving in the last 3 years?


If Yes, please explain.


Do all drivers TOTALLY ABSTAIN AT ALL TIMES from drinking alcohol?  


Please feal free to provide any additional information that you feal is necessary in order to serve you better.