Fabbro & Douglas Insurance quote forms

Name:

Address:

City:

Province:

Postal Code:

Phone number:

Email:

Driver's License #:

Year G1 Attained:

Year G2 Attained:

Year G Attained:

Number of driving convictions in past three years:

Year, make, and model of vehicle:

Do you use your vehicle for business:

YesNo

Do you use your vehicle to commute to and from work:

YesNo

If so, number of km one way to work:

# of years you have consistently had an auto policy in force or been listed as a driver on someone else’s policy:

Number of at fault claims in the past 10 years:

If any, the approximate date of the last claim:

Policy cancelled for non-payment in the past 3 years?:

YesNo

Was your policy lapsed for any other reason by the insurance company:

Liability limit requested:

Coverage Preferred:

Deductible:

Current insurance company and renewal date:

Which insurance company has your current property insurance:

Marital status of principal driver:

Additional vehicles to be quoted:

YesNo

Are there other household drivers?:

YesNo

Driver 1:

Driver 2:

Driver 3:

Auto Insurance