Information for Commercial Auto Quotation

What Broker are you working with?(Required)

How did you hear about Jones Insurance?(Required)

If you can, please tell us more or who sent you our way.

Legal Business Name:

The name of who the vehicle is registered to.

Operating Name:

What name does your business go by?

Owner / Operator:(Required)

First Name

Last Name

Email(Required)

Phone(Required)

Is the Primary Business Contact the same as the Owner / Operator?(Required)

Yes

Primary Business Contact Name

First Last

Phone

Business Address:(Required)

Street Address Address Line 2 City Province Postal Code

Preferred Method of Contact:(Required)

Phone

What date should coverage begin?(Required)

MM slash DD slash YYYY

Do you currently have Commercial Auto Insurance?(Required)

Yes

Current Commercial Auto Insurance Company:

When is your renewal date?

MM slash DD slash YYYY

Do you currently have Commercial General Liability (CGL) Insurance?(Required)

Yes

Current CGL Insurance Company:

Renewal Date:

MM slash DD slash YYYY

Has your commercial auto policy been cancelled for non-payment in the last 9 years?(Required)

Yes

What year was your insurance last cancelled for non-payment?

How many times has your policy lapsed (expired) in the past 9 years?(Required)

Drivers & Vehicles

How many drivers are there on this policy?(Required)

How many vehicles are there on this policy?(Required)

Principle Operator (Driver #1)

Name (Principle Operator - Driver #1):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my complete driver's abstract history for myself and declare that I have obtained consent for all other permitted drivers. I understand that disclosing the driving history of all permitted driver’s is required to quote and issue a commercial auto policy.

I agree

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

G Acquisition Date:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Continuously Insured Since:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Gender:(Required)

How many at-fault accidents have you been in over the past 9 years?(Required)

How many tickets or charges related to your driving in the past 3 years?(Required)

Has your insurance ever been cancelled for 'misrepresentation' in the past?

Driver #2

Name (Driver #2):(Required)

First Last

Driver's License Consent:(Required)

Yes

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

G Acquisition Date:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Continuously Insured Since:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Gender:(Required)

How many at-fault accidents have you been in over the past 9 years?(Required)

How many tickets or charges related to your driving in the past 3 years?(Required)

Has your insurance ever been cancelled for 'misrepresentation' in the past?

Driver #3

Name (Driver #3):(Required)

First Last

Driver's License Consent:(Required)

I agree

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

G Acquisition Date:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Continuously Insured Since:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Gender:(Required)

How many at-fault accidents have you been in over the past 9 years?(Required)

How many tickets or charges related to your driving in the past 3 years?(Required)

Has your insurance ever been cancelled for 'misrepresentation' in the past?

Driver #4

Name (Driver #4):(Required)

First Last

Driver's License Consent:(Required)

I agree

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

G Acquisition Date:

MM slash DD slash YYYY

Continuously Insured Since:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Gender:

This information will be required before we can bind coverage.

How many at-fault accidents have you been in over the past 9 years?(Required)

How many tickets or charges related to your driving in the past 3 years?(Required)

Has your insurance ever been cancelled for 'misrepresentation' in the past?

Driver #5

Name (Driver #5):(Required)

First Last

Driver's License Consent:(Required)

I agree

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

G Acquisition Date:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Continuously Insured Since:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Gender:(Required)

How many at-fault accidents have you been in over the past 9 years?(Required)

How many tickets or charges related to your driving in the past 3 years?(Required)

Has your insurance ever been cancelled for 'misrepresentation' in the past?

Driver #6

Name (Driver #6):(Required)

First Last

Driver's License Consent:(Required)

I agree

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

G Acquisition Date:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Continuously Insured Since:

MM slash DD slash YYYY

This information will be required before we can bind coverage.

Gender:(Required)

How many at-fault accidents have you been in over the past 9 years?(Required)

How many tickets or charges related to your driving in the past 3 years?(Required)

Has your insurance ever been cancelled for 'misrepresentation' in the past?

Vehicle Information (Vehicle #1)

Registered Gross Weight of Vehicle:

This can be found on the ownership of the vehicle.

Above 4500 Kilograms

Below 4500 Kilograms

Do you have at least 3 years’ experience driving a vehicle of similar weight/class?(Required)

Yes

Please attach your Letter of Experience

Max. file size: 32 MB.

A letter of experience confirms a heavy truck driver's proper insurance coverage, details their history of violations and claims and is obtained by requesting it from their employer. The commercial insurance company issues the letter, outlining the driver's driving experience with the specified vehicle type, including the gross vehicle weight.

Do you have a CVOR (Commercial Vehicle Operators Registration) for this vehicle?(Required)

Yes

A CVOR is a unique identifier assigned to commercial vehicles operating in Canada.

CVOR Number:

The CVOR certificate identifies the carrier and contains a unique nine-digit identification number.

Please upload a copy of the CVOR Certificate:

Drop files here or

Max. file size: 32 MB.

Please attach your Level 2 CVOR Report(s)

Accepted file types: pdf, docx, Max. file size: 32 MB.

A CVOR Level 2 offers an in-depth report for the carrier, with detailed information about driver infractions, collisions, and vehicle inspections.

Relationship of the Principal Operator of This Vehicle to the Applicant:(Required)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principal Operator (PO) or Additional Driver (AD)

Use the "+" icon to add more drivers.

Trailer

Is this vehicle a hauling trailer?(Required)

Yes

Trailer

What materials are carried?

Year(Required)

Make(Required)

Model(Required)

Length(Required)

Replacement Value(Required)

Trailer Serial Number(Required)

Vehicle

Year(Required)

Make(Required)

Model(Required)

VIN #:(Required)

Parked Postal Code:(Required)

Where is this vehicle parked at night?

Percentage Used For Business:(Required)

Purchase Price:

Purchase Date:

MM slash DD slash YYYY

Was this vehicle purchased new or used?

New

Used

Operation Details (Vehicle #1)

On average, how far do you drive one-way to a job site?(Required)

Radius Minimum

Radius Maximum

How many times a month do you drive further than your average one-way commute? (To jobs outside of usual operations, to receive maintenance work, etc.)(Required)

What is the approximate distance and location you travel to in these instances?(Required)

How many kilometres will you drive annually?(Required)

What is the use of the vehicle? (Select all that apply)(Required)

Carrying equipment & tools

Storing equipment & tools

Delivery

Hauling trailer

Used seasonally

Other

If 'other', please specify what the use of the vehicle is:(Required)

What materials are carried or stored in the vehicle?(Required)

Example: Inventory, Supplies, Equipment, Cash Deposits, etc.

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Yes

Explain the modifications or damage:(Required)

Is there Attached Equipment on the vehicle?(Required)

Yes

Please list the equipment:(Required)

Add additional equipment by click the "+" icon.

Equipment

Value

What is the total value of the equipment?(Required)

Coverage (Vehicle #1)

In the event of an accident...

Comprehensive

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage

Do you require coverage for a rental vehicle in the event of a claim?

Yes

Accident Forgiveness

Do you want to ensure your driving record remains the same with your insurance company in the event of an at-fault accident?

Yes

Additional Liability for Rented Vehicles

Would you like your coverage to extend to a vehicle you rent or borrow?

Yes

Vehicle Information (Vehicle #2)

Registered Gross Weight of Vehicle:

This can be found on the ownership of the vehicle.

Above 4500 Kilograms

Below 4500 Kilograms

Do you have at least 3 years’ experience driving a vehicle of similar weight/class?(Required)

Yes

Please attach your Letter of Experience

Max. file size: 32 MB.

Do you have a CVOR (Commercial Vehicle Operators Registration) for this vehicle?(Required)

Yes

A CVOR is a unique identifier assigned to commercial vehicles operating in Canada.

CVOR Number:

The CVOR certificate identifies the carrier and contains a unique nine-digit identification number.

Please upload a copy of the CVOR Certificate:

Drop files here or

Max. file size: 32 MB.

Please attach your Level 2 CVOR Report(s)

Accepted file types: pdf, docx, Max. file size: 32 MB.

A CVOR Level 2 offers an in-depth report for the carrier, with detailed information about driver infractions, collisions, and vehicle inspections.

Relationship of the Principal Operator of This Vehicle to the Applicant:(Required)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principal Operator (PO) or Additional Driver (AD)

Use the "+" icon to add more drivers.

Trailer

Is this vehicle a hauling trailer?(Required)

Yes

Trailer

What materials are carried?

Year(Required)

Make(Required)

Model(Required)

Length(Required)

Replacement Value(Required)

Trailer Serial Number(Required)

Vehicle

Year(Required)

Make(Required)

Model(Required)

VIN #:(Required)

Parked Postal Code:(Required)

Where is this vehicle parked at night?

Percentage Used For Business:(Required)

Purchase Price:

Purchase Date:

MM slash DD slash YYYY

Was this vehicle purchased new or used?

New

Used

Operation Details (Vehicle #2)

On average, how far do you drive one-way to a job site?(Required)

Radius Minimum

Radius Maximum

How many times a month do you drive further than your average one-way commute? (To jobs outside of usual operations, to receive maintenance work, etc.)(Required)

What is the approximate distance and location you travel to in these instances?(Required)

How many kilometres will you drive annually?(Required)

What is the use of the vehicle? (Select all that apply)(Required)

Carrying equipment & tools

Storing equipment & tools

Hauling trailer

Used seasonally

Other:

If 'other', please specify what the use of the vehicle is:(Required)

What materials are carried or stored in the vehicle?(Required)

Example: Inventory, Supplies, Equipment, Cash Deposits, etc.

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Yes

Explain the modifications or damage:(Required)

Is there Attached Equipment on the vehicle?(Required)

Yes

Please list the equipment:(Required)

Add additional equipment by click the "+" icon.

Equipment

Value

What is the total value of the equipment?(Required)

Coverage (Vehicle #2)

In the event of an accident...

Comprehensive

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage

Do you require coverage for a rental vehicle in the event of a claim?

Yes

Accident Forgiveness

Do you want to ensure your driving record remains the same with your insurance company in the event of an at-fault accident?

Yes

Additional Liability for Rented Vehicles

Would you like your coverage to extend to a vehicle you rent or borrow?

Yes

Vehicle Information (Vehicle #3)

Registered Gross Weight of Vehicle:

This can be found on the ownership of the vehicle.

Above 4500 Kilograms

Below 4500 Kilograms

Do you have at least 3 years’ experience driving a vehicle of similar weight/class?(Required)

Yes

Please attach your Letter of Experience

Max. file size: 32 MB.

Do you have a CVOR (Commercial Vehicle Operators Registration) for this vehicle?(Required)

Yes

A CVOR is a unique identifier assigned to commercial vehicles operating in Canada.

CVOR Number:

The CVOR certificate identifies the carrier and contains a unique nine-digit identification number.

Please upload a copy of the CVOR Certificate:

Drop files here or

Max. file size: 32 MB.

Please attach your Level 2 CVOR Report(s)

Accepted file types: pdf, docx, Max. file size: 32 MB.

A CVOR Level 2 offers an in-depth report for the carrier, with detailed information about driver infractions, collisions, and vehicle inspections.

Relationship of the Principal Operator of This Vehicle to the Applicant:(Required)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principal Operator (PO) or Additional Driver (AD)

Use the "+" icon to add more drivers.

Trailer

Is this vehicle a hauling trailer?(Required)

Yes

Trailer

What materials are carried?

Year(Required)

Make(Required)

Model(Required)

Length(Required)

Replacement Value(Required)

Trailer Serial Number(Required)

Vehicle

Year(Required)

Make(Required)

Model(Required)

VIN #:(Required)

Parked Postal Code:(Required)

Where is this vehicle parked at night?

Percentage Used For Business:(Required)

Purchase Price:

Purchase Date:

MM slash DD slash YYYY

Was this vehicle purchased new or used?

New

Used

Operation Details (Vehicle #3)

On average, how far do you drive one-way to a job site?(Required)

Radius Minimum

Radius Maximum

How many times a month do you drive further than your average one-way commute? (To jobs outside of usual operations, to receive maintenance work, etc.)(Required)

What is the approximate distance and location you travel to in these instances?(Required)

How many kilometres will you drive annually?(Required)

What is the use of the vehicle? (Select all that apply)(Required)

Carrying equipment & tools

Storing equipment & tools

Hauling trailer

Used seasonally

Other:

If 'other', please specify what the use of the vehicle is:(Required)

What materials are carried or stored in the vehicle?(Required)

Example: Inventory, Supplies, Equipment, Cash Deposits, etc.

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Yes

Explain the modifications or damage:(Required)

Is there Attached Equipment on the vehicle?(Required)

Yes

Please list the equipment:(Required)

Add additional equipment by click the "+" icon.

Equipment

Value

What is the total value of the equipment?(Required)

Coverage (Vehicle #3)

In the event of an accident...

Comprehensive

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage

Do you require coverage for a rental vehicle in the event of a claim?

Yes

Accident Forgiveness

Do you want to ensure your driving record remains the same with your insurance company in the event of an at-fault accident?

Yes

Additional Liability for Rented Vehicles

Would you like your coverage to extend to a vehicle you rent or borrow?

Yes

Vehicle Information (Vehicle #4)

Registered Gross Weight of Vehicle:

This can be found on the ownership of the vehicle.

Above 4500 Kilograms

Below 4500 Kilograms

Do you have at least 3 years’ experience driving a vehicle of similar weight/class?(Required)

Yes

Please attach your Letter of Experience

Max. file size: 32 MB.

Do you have a CVOR (Commercial Vehicle Operators Registration) for this vehicle?(Required)

Yes

A CVOR is a unique identifier assigned to commercial vehicles operating in Canada.

CVOR Number:

The CVOR certificate identifies the carrier and contains a unique nine-digit identification number.

Please upload a copy of the CVOR Certificate:

Drop files here or

Max. file size: 32 MB.

Please attach your Level 2 CVOR Report(s)

Accepted file types: pdf, docx, Max. file size: 32 MB.

A CVOR Level 2 offers an in-depth report for the carrier, with detailed information about driver infractions, collisions, and vehicle inspections.

Relationship of the Principal Operator of This Vehicle to the Applicant:(Required)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principal Operator (PO) or Additional Driver (AD)

Use the "+" icon to add more drivers.

Trailer

Is this vehicle a hauling trailer?(Required)

Yes

Trailer

What materials are carried?

Year(Required)

Make(Required)

Model(Required)

Length(Required)

Replacement Value(Required)

Trailer Serial Number(Required)

Vehicle

Year(Required)

Make(Required)

Model(Required)

VIN #:(Required)

Parked Postal Code:(Required)

Where is this vehicle parked at night?

Percentage Used For Business:(Required)

Purchase Price:

Purchase Date:

MM slash DD slash YYYY

Was this vehicle purchased new or used?

New

Used

Operation Details (Vehicle #4)

On average, how far do you drive one-way to a job site?(Required)

Radius Minimum

Radius Maximum

How many times a month do you drive further than your average one-way commute? (To jobs outside of usual operations, to receive maintenance work, etc.)(Required)

What is the approximate distance and location you travel to in these instances?(Required)

How many kilometres will you drive annually?(Required)

What is the use of the vehicle? (Select all that apply)(Required)

Carrying equipment & tools

Storing equipment & tools

Hauling trailer

Used seasonally

Other:

If 'other', please specify what the use of the vehicle is:(Required)

What materials are carried or stored in the vehicle?(Required)

Example: Inventory, Supplies, Equipment, Cash Deposits, etc.

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Yes

Explain the modifications or damage:(Required)

Is there Attached Equipment on the vehicle?(Required)

Yes

Please list the equipment:(Required)

Add additional equipment by click the "+" icon.

Equipment

Value

What is the total value of the equipment?(Required)

Coverage (Vehicle #4)

In the event of an accident...

Comprehensive

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage

Do you require coverage for a rental vehicle in the event of a claim?

Yes

Accident Forgiveness

Do you want to ensure your driving record remains the same with your insurance company in the event of an at-fault accident?

Yes

Additional Liability for Rented Vehicles

Would you like your coverage to extend to a vehicle you rent or borrow?

Yes

Vehicle Information (Vehicle #5)

Registered Gross Weight of Vehicle:

This can be found on the ownership of the vehicle.

Above 4500 Kilograms

Below 4500 Kilograms

Do you have at least 3 years’ experience driving a vehicle of similar weight/class?(Required)

Yes

Please attach your Letter of Experience

Max. file size: 32 MB.

Do you have a CVOR (Commercial Vehicle Operators Registration) for this vehicle?(Required)

Yes

A CVOR is a unique identifier assigned to commercial vehicles operating in Canada.

CVOR Number:

The CVOR certificate identifies the carrier and contains a unique nine-digit identification number.

Please upload a copy of the CVOR Certificate:

Drop files here or

Max. file size: 32 MB.

Please attach your Level 2 CVOR Report(s)

Accepted file types: pdf, docx, Max. file size: 32 MB.

A CVOR Level 2 offers an in-depth report for the carrier, with detailed information about driver infractions, collisions, and vehicle inspections.

Relationship of the Principal Operator of This Vehicle to the Applicant:(Required)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principal Operator (PO) or Additional Driver (AD)

Use the "+" icon to add more drivers.

Trailer

Is this vehicle a hauling trailer?(Required)

Yes

Trailer

What materials are carried?

Year(Required)

Make(Required)

Model(Required)

Length(Required)

Replacement Value(Required)

Trailer Serial Number(Required)

Vehicle

Year(Required)

Make(Required)

Model(Required)

VIN #:(Required)

Parked Postal Code:(Required)

Where is this vehicle parked at night?

Percentage Used For Business:(Required)

Purchase Price:

Purchase Date:

MM slash DD slash YYYY

Was this vehicle purchased new or used?

New

Used

Operation Details (Vehicle #5)

On average, how far do you drive one-way to a job site?(Required)

Radius Minimum

Radius Maximum

How many times a month do you drive further than your average one-way commute? (To jobs outside of usual operations, to receive maintenance work, etc.)(Required)

What is the approximate distance and location you travel to in these instances?(Required)

How many kilometres will you drive annually?(Required)

What is the use of the vehicle? (Select all that apply)(Required)

Carrying equipment & tools

Storing equipment & tools

Hauling trailer

Used seasonally

Other:

If 'other', please specify what the use of the vehicle is:(Required)

What materials are carried or stored in the vehicle?(Required)

Example: Inventory, Supplies, Equipment, Cash Deposits, etc.

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Yes

Explain the modifications or damage:(Required)

Is there Attached Equipment on the vehicle?(Required)

Yes

Please list the equipment:(Required)

Add additional equipment by click the "+" icon.

Equipment

Value

What is the total value of the equipment?(Required)

Coverage (Vehicle #5)

In the event of an accident...

Comprehensive

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage

Do you require coverage for a rental vehicle in the event of a claim?

Yes

Accident Forgiveness

Do you want to ensure your driving record remains the same with your insurance company in the event of an at-fault accident?

Yes

Additional Liability for Rented Vehicles

Would you like your coverage to extend to a vehicle you rent or borrow?

Yes

Vehicle Information (Vehicle #6)

Registered Gross Weight of Vehicle:

This can be found on the ownership of the vehicle.

Above 4500 Kilograms

Below 4500 Kilograms

Do you have at least 3 years’ experience driving a vehicle of similar weight/class?(Required)

Yes

Please attach your Letter of Experience

Max. file size: 32 MB.

Do you have a CVOR (Commercial Vehicle Operators Registration) for this vehicle?(Required)

Yes

A CVOR is a unique identifier assigned to commercial vehicles operating in Canada.

CVOR Number:

The CVOR certificate identifies the carrier and contains a unique nine-digit identification number.

Please upload a copy of the CVOR Certificate:

Drop files here or

Max. file size: 32 MB.

Please attach your Level 2 CVOR Report(s)

Accepted file types: pdf, docx, Max. file size: 32 MB.

A CVOR Level 2 offers an in-depth report for the carrier, with detailed information about driver infractions, collisions, and vehicle inspections.

Relationship of the Principal Operator of This Vehicle to the Applicant:(Required)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principal Operator (PO) or Additional Driver (AD)

Use the "+" icon to add more drivers.

Trailer

Is this vehicle a hauling trailer?(Required)

Yes

Trailer

What materials are carried?

Year(Required)

Make(Required)

Model(Required)

Length(Required)

Replacement Value(Required)

Trailer Serial Number(Required)

Vehicle

Year(Required)

Make(Required)

Model(Required)

VIN #:(Required)

Parked Postal Code:(Required)

Where is this vehicle parked at night?

Percentage Used For Business:(Required)

Purchase Price:

Purchase Date:

MM slash DD slash YYYY

Was this vehicle purchased new or used?

New

Used

Operation Details (Vehicle #6)

On average, how far do you drive one-way to a job site?(Required)

Radius Minimum

Radius Maximum

How many times a month do you drive further than your average one-way commute? (To jobs outside of usual operations, to receive maintenance work, etc.)(Required)

What is the approximate distance and location you travel to in these instances?(Required)

How many kilometres will you drive annually?(Required)

What is the use of the vehicle? (Select all that apply)(Required)

Carrying equipment & tools

Storing equipment & tools

Hauling trailer

Used seasonally

Other:

If 'other', please specify what the use of the vehicle is:(Required)

What materials are carried or stored in the vehicle?(Required)

Example: Inventory, Supplies, Equipment, Cash Deposits, etc.

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Yes

Explain the modifications or damage:(Required)

Is there Attached Equipment on the vehicle?(Required)

Yes

Please list the equipment:(Required)

Add additional equipment by click the "+" icon.

Equipment

Value

What is the total value of the equipment?(Required)

Coverage (Vehicle #6)

In the event of an accident...

Comprehensive

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage

Do you require coverage for a rental vehicle in the event of a claim?

Yes

Accident Forgiveness

Do you want to ensure your driving record remains the same with your insurance company in the event of an at-fault accident?

Yes

Additional Liability for Rented Vehicles

Would you like your coverage to extend to a vehicle you rent or borrow?

Yes

Privacy

Consent(Required)

I agree to the privacy policy.

As part of my application for insurance, I hereby consent to the brokerage firm named below (the
“Broker”) collecting, using, and disclosing my personal information, including my insurance and claims history, for purposes of obtaining quotes for me for new or renewal personal lines insurance,
property/casualty and/or automobile insurance, as applicable, and to provide such personal information to third parties for this purpose, including to disclose this information to insurance companies and third-party insurance rating service providers for the purposes of their assessing risk, determining my eligibility for insurance coverage and setting premiums (“Underwriting Purposes”). I understand that information will be collected directly from me and from third parties such as credit bureaus, the Ministry of Transportation, other insurers, and insurance rating service providers.

I understand that, for automobile insurance Underwriting Purposes, some insurers may require up to 25 years of personal information such as driving record and claims history about me and all other permitted drivers and agree to provide the requested information. I represent and warrant that I have obtained consent from the other permitted drivers to also grant this permission in relation to their personal information.

I understand that the Broker may be required or permitted to disclose my personal information without my consent pursuant to relevant privacy laws or other laws. The Broker will otherwise handle my personal information in accordance with its privacy policy, which is available on request. If I wish to review personal information pertaining to my application or policy maintained by the Broker, obtain copies of the Broker’s privacy policies or standards, or make other enquiries or express concerns, I understand that I may do so by contacting the Broker’s Privacy Officer. I understand I can access further guidelines on Broker Conduct and the Fair Treatment of Customers online or by request.

I understand that I may withdraw consent at any time on reasonable notice and that if I do so, the Broker may not be able to provide me with the requested quote(s).

Additional Notes or Information

Name

This field is for validation purposes and should be left unchanged.

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