Instar Insurance Brokers Inc.

 

Automobile Insurance
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CONTACT INFORMATION
Surname: * First Name:
Telephone:
E-mail: *
City:
Province: * Postal Code:
Employer/Association:
VEHICLE INFORMATION
Year: Body Type:
Make:
(eg.Honda)		 Full Model Name:
(eg.Civic DX)
Drive to work? Yes  No Used for business? Yes  No
Car alarm? Yes  No Distance to work/school:
Annual Kilometres:
PRINCIPAL DRIVER
Age:  Years Licensed in Canada:
Licence Class:
If Licensed after 1994, when were you licensed for (month/year): G1:
G2:
G:  
Driver Training Certificate: Yes    No    
At Fault Claims in past 10 years (month/year) Description:
Any Other Claims in the Past 6 years?
Any Suspensions in the Past 6 years? Description:
Traffic Violations or Criminal Offenses in last 3 years:
Any Cancellations/Loss of Coverage: Yes    No    
OCCASIONAL DRIVER
Age:  Years Licensed in Canada:
Gender: Female    Male   
If Licensed after 1994, when were you licensed for (month/year): G1:
G2:
G:   
Driver Training Certificate: Yes    No   
Claims or License
Suspension in last 6 years:
Traffic Violations or Criminal Offenses in last 3 years:
INSURANCE
Proof of insurance during the past 6 years? Yes   No
Desired Coverage: Liability
 Collision Deductible
  Comprehensive Coverage
Renewal Date: (mm-dd-yyyy)
Please tell us how you found our site: Fairlie Insurance Agency
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Instar Insurance Brokers
2435 Holly Lane, Suite 200
Ottawa, ON  K1V 7P2
Tel. 613-228-1600
Fax: 613-232-6486
Email: info@instar.on.ca