Crosbie Job Insurance
Earning your Trust snce the 1800's

Automobile Insurance Quote

Quotation will be based on information given. If a policy is purchased based on this quote, information will be obtained from the previous insurance company and driving records will be obtained from motor registration. Information obtained from either could change the premium quoted.

(*Required Fields)

Name:

*Email Address:

Address:

Registered Owner:

Current or Most Recent Insurer:

Expiry Date:

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Vehicle Information

 
Vehicle # 1
Vehicle # 2
Vehicle # 3
Vehicle # 4
Year
Trade Name
Model
Body Type
Purchase Price
Liability
(mandatory)
ACC/MED
All Perils
Collision - Deductible
Comprehensive - Deductible
Specified Perils-
Deductible
Deletion of lass
Coverage
Family rotection
Coverage
Loss of Use
Limited Waiver of Depreciation
Legal Liability For Non-Owned Vehicles

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Driver Information
 
Principal Driver
Driver # 2
Driver # 3
Driver # 4
Name
Age of Driver
How Long Licensed
Drivers Licence
Any Approved Driver Training
Is Vehicle Used to Commute to Work or School
Distance One Way-KMS
Annual KMS
Moving Violations (Past 3 Yrs.) Give Dates & Types
Major Convictions (Past 6 Yrs.) Give Dates & Types
Claims (Past 6 Yrs.) - Incld. Glass Give Dates & Types
Occupation
Medical Disabilities that Would Affect Safe Vehicle Operation
Drives Which Vehicle
Percentage of Use

Any Other Drivers in Household:

Do They Have Their Own Vehicles or Insurance:

   

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