Monday, 06 February 2012
49 Norfolk St. N., Simcoe ON (519) 426-2031

Application for Auto Insurance

Privacy Policy

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I have read and understood R.E. Mann's Privacy Policy  Yes

Once you have verified that you have read the privacy policy above by clicking the Yes button you can continue your application.

General Info

Please enter a valid email address.

Current Auto Insurance Info

Presently Insured:  Yes  No

Drivers Info

DR
#		 Drivers
Name		 DOB
(dd/mm/yyyy)		 Sex
MF		 Licence -
G		 Date Obtained
G1		 (dd/mm/yyyy)
G2
1
2
3
4
DR # Has Driver Training  ? Year Completed
1  Yes      No
2  Yes      No
3  Yes      No
4  Yes      No

Any other persons in the home with a valid drivers license?
If yes - more information may be required.  Yes  No

Any accidents or claims in the last 10 years?  Yes  No If Yes, please specify below:


DR#
?		 Date
(dd/mm/yyyy)		 Claim Details
?
Any convictions in the last 3 years?  Yes  No If Yes, please specify below:


DR#
?		 Date
(dd/mm/yyyy)		 Type of Conviction
?
Any license suspensions in the last 6 years?  Yes  No If Yes, please specify below:


DR#
?		 Date Suspended
(dd/mm/yyyy)		 Reason for Suspension
?		 Date Reinstated
(dd/mm/yyyy)

Vehicle Information

V# Year Make & Model Body Type VIN To Work
1 Way(km)		 Annual
(km)		 DR#
?
1
2
3

Coverages

  Vehicle 1 Vehicle 2 Vehicle 3
Liability ?
Comprehensive ?
Collision ?
Rental ?
Due to insured peril
 
Accident Waivers ?
For those that qualify
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