Legal name of secondary driver
Where will you be operating your vehicle most of the time?
Out of the lower mainland but in BC
Other provinces other than BC
Marital status of principal driver?
Please outline if vehicle is used for delivery of goods, taxi, towing a trailer, renting vehicle to others?
# years at fault free ? (ie: no losses that were your fault)
2nd Named Insured Owner if applicable
Do all insureds/drivers consent to a credit scoring check to maximize the discounts available on your policy?
Birthdate of secondary driver
# of major motor vehicle convictions last 10 years?
1st named insured owner
Confirm if vehicle status is "rebuilt". Check your current icbc vehicle registration papers if you are unsure.
List any other secondary drivers legal name(s), birthdate(s), Marital status
Address of where vehicle will be kept normally when not in use?
Type of fuel:
How did you find out about our office?
I am already an existing client
I was referred by someone
I found you via google, facebook or other social media
I am a client of one of your staff members
I noticed your office when I was driving/walking by.
Please list any loss payee or lessee name and mailing address if applicable?
Click below any optional coverages you are interested in?
Glass - Windshield Exclusion endorsement
Excess under insured motorist protection
Auto Expert Driver Package
Limited Waiver of Depreciation
Limited Waiver of Depreciation - Lessee
Replacement cost endorsement
Permission to rent or lease endorsement
How long have you owned the vehicle in years?
Principal Residence - House
Principal Residence - Condo
Condo Rented to Others
Rental property - House
Home - New Construction
General Building Contractors
Janitorial & Cleaning
Plumbing, Heating, HVAC Contractors
Building Valuation Replacement cost
Commercial Strata Unit Owners
Auto & Boat
Boats - pleasurecraft
Total purchase price of vehicle including taxes?
# years continuously insured?
# years licensed?
# of motor vehicle convictions in last 10 years?
Birthdate of secondary driver
Estimated Annual number of Km's driven for business purposes?
Thank you for contacting us! I We will contact you within 2 business days!
# at fault losses in the last 10 years?
Date Canadian drivers license was obtained for principal driver?
Email Address of Insured
Birthdate of principal driver?
Is this the first time you are insuring this vehicle?
Best Phone number to call you back at:
Do you have an anti-theft device?
Date Canadian drivers license was obtained for secondary driver?
Attach a copy of any current or previous auto insurance?
We were unable to upload your file. Please ensure your file is 10MB or smaller in size.
Liability limit requested over & above the compulsory $200,000. government insurance?
Number of kilometers driven to your location of work ONE way:
less than 15 kms
more than 15 kms
I drive to different locations each day for business
Comprehensive deductible desired?
# NOT at fault losses in last 10 years?
Your mailing address
Describe the type of anti-theft device
Make of vehicle
Collision deductible desired?
When do you require optional insurance for this vehicle? Do not delete any coverages on your current policy until any new policy is in place.
Do you have any home or auto currently insured with Intact insurance? If so, list policy numbers below
Legal Name of principal driver
Are any insureds and/or drivers being charged a drivers risk premium? If so, indicate persons name.
Estimated Annual number of Km's driven?
John Fleming Insurance Agency
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