StoneRidge Car Insurance - StoneRidge Insurance Brokers Chatham-Kent

Full Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Email*

Phone Number*

Have You Ever Had Insurance Cancelled or Refused?

Yes
No

Do You currently Insure Your Car?

Yes
No

If not have you had insurance for 12 consecutive months within the last 6 years?

Yes
No

Enter the number of drivers to be insured

One
Two
Three
Four

Driver 1 Information

Driver #1 Full Name

First Last

Driver #1 Licence #

Driver #1 Years Licensed in Canada

Driver #1 Licence Class

Driver #1 Gender

Driver #1 Marital Status

Driver #1 Driving School

Yes
No

Driver #1 Retired

Yes
No

Driver #1 Minor Traffic Convictions in the Last 3 Years

Driver #1 Major Traffic Convictions in the Last 3 Years

Driver #1 Are You Currently Insured?

Yes
No

Driver #1 Name of Previous Insurance Company

Driver 2 Information

Driver #2 Full Name

First Last

Driver #2 Licence #

Driver #2 Years Licensed in Canada

Driver #2 Licence Class

Driver #2 Gender

Driver #2 Marital Status

Driver #2 Driving School

Yes
No

Driver #2 Retired

Yes
No

Driver #2 Minor Traffic Convictions in the Last 3 Years

Driver #2 Major Traffic Convictions in the Last 3 Years

Driver #2 Are You Currently Insured?

Yes
No

Driver #2 Name of Previous Insurance Company

Driver 3 Information

Driver #3 Full Name

First Last

Driver #3 Licence #

Driver #3 Years Licensed in Canada

Driver #3 Licence Class

Driver #3 Gender

Driver #3 Marital Status

Driver #3 Driving School

Yes
No

Driver #3 Retired

Yes
No

Driver #3 Minor Traffic Convictions in the Last 3 Years

Driver #3 Major Traffic Convictions in the Last 3 Years

Driver #3 Are You Currently Insured?

Yes
No

Driver #3 Name of Previous Insurance Company

Driver 4 Information

Driver #4 Full Name

First Last

Driver #4 Licence #

Driver #4 Years Licensed in Canada

Driver #4 Licence Class

Driver #4 Gender

Driver #4 Marital Status

Driver #4 Driving School

Yes
No

Driver #4 Retired

Yes
No

Driver #4 Minor Traffic Convictions in the Last 3 Years

Driver #4 Major Traffic Convictions in the Last 3 Years

Driver #4 Are You Currently Insured?

Yes
No

Driver #4 Name of Previous Insurance Company

Claims Information

Have any of the drivers above had accidents in the past 10 years?

Yes
No

If Yes, how many claims in the past 10 years?

One
Two
Three

Have any of the drivers above had their licence suspended or lapsed in the past 6 years?

Yes
No

Claims #1 Information

Claim #1 Details

Claim #1 Date

Claim #1 Driver

Claims #2 Information

Claim #2 Details

Claim #2 Date

Claim #2 Driver

Claims #3 Information

Claim #3 Details

Claim #3 Date

Claim #3 Driver

Vehicle Information

Enter # of Vehicles to be Insured

One
Two
Three
Four

Vehicle #1

Vehicle #1 Make

Vehicle #1 Year

Vehicle #1 Model

Vehicle #1 Style

Vehicle #1 Use

Vehicle #1 Km Driven One Way to Work

Vehicle #1 Kilometers Driven per Year

Vehicle #1 Who is the Primary Driver?

Vehicle #1 Liability Coverage Required

Vehicle #1 Collision Deductible Coverage Required

Vehicle #1 Comprehensive Deductible Coverage Required

Vehicle #2

Vehicle #2 Make

Vehicle #2 Year

Vehicle #2 Model

Vehicle #2 Style

Vehicle #2 Use

Vehicle #2 Km Driven One Way to Work

Vehicle #2 Kilometers Driven per Year

Vehicle #2 Who is the Primary Driver?

Vehicle #2 Liability Coverage Required

Vehicle #2 Collision Deductible Coverage Required

Vehicle #2 Comprehensive Deductible Coverage Required

Vehicle #3

Vehicle #3 Make

Vehicle #3 Year

Vehicle #3 Model

Vehicle #3 Style

Vehicle #3 Use

Vehicle #3 Km Driven One Way to Work

Vehicle #3 Kilometers Driven per Year

Vehicle #3 Who is the Primary Driver?

Vehicle #3 Liability Coverage Required

Vehicle #3 Collision Deductible Coverage Required

Vehicle #3 Comprehensive Deductible Coverage Required

Vehicle #4

Vehicle #4 Make

Vehicle #4 Year

Vehicle #4 Model

Vehicle #4 Style

Vehicle #4 Use

Vehicle #4 Km Driven One Way to Work

Vehicle #4 Kilometers Driven per Year

Vehicle #4 Who is the Primary Driver?

Vehicle #4 Liability Coverage Required

Vehicle #4 Collision Deductible Coverage Required

Vehicle #4 Comprehensive Deductible Coverage Required

Comments

Disclaimer

Disclaimer*

I understand the following disclaimer (listed below)

This is a request to provide a quote only and is not an insurance policy. It is not an offer of insurance. Further information may be required in order for a complete quote to be provided.

This quote request contains some information about coverage offered but it does not list all of the conditions and exclusions that apply to the described coverage. The actual wording of the policy governs all situations.

This quote request is only available to persons resident in the Province of Ontario.The products described are subject to change without notice at any time.