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Free and Fast Auto Insurance Quotes

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Welcome

On Line Auto Quote Form

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(Red Areas Are REQUIRED)

General Information

Your Name:
Street Address:
City:
Province:
Postal Code:
Email (REQUIRED):
Email Again for Accuracy:
Phone:
Fax (optional):
Marital Status: Single Married	Homeowner or Renter? Home Renter
Currently Insured?	Yes No
Current Company?

Driver # 1

Name:		Birthdate:
Sex (M/F):		Ontario Drivers License #
G1 Lic. Date:		G2 Lic. Date:
G Lic. Date:		Current Lic. Class:
Number of Accidents in the last 3 years:		Number of MINOR tickets in last 3 years:
Number of MAJOR tickets in last 3 years:		Daily commute in ONE WAY kms:
Has any Company cancelled or refused you insurance in the last 3 years? eg. nonpayments	Yes No	If Yes, for What Reason?

Driver # 2

Name:		Birthdate:
Sex (M/F):		Ontario Drivers License # & Class of License:
Number of Accidents in the last 3 years:		Number of MINOR tickets in last 3 years:
Number of MAJOR tickets in last 3 years:		Daily commute in ONE WAY kms:
Has any Company cancelled or refused you insurance in the last 3 years? eg. nonpayments	Yes No	If Yes, for What Reason?

VEHICLE #1 INFORMATION


Year of vehicle:		Make & Model:
VIN# (for rating accuracy):
Annual Kms:		Business Use? (Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits

Select Comprehensive Deductible:

Select Collision Deductible:

Do You Have a Drivers Training Certificate?	YES NO

VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:		Make & Model:
VIN# (for rating accuracy):
Annual Kms:		Business Use? (Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits	- - - Liability Limits Must Match Vehicle #1 - - -

Select Comprehensive Deductible:

Select Collision Deductible:

If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:
Comments or Remarks: (List additional drivers, autos, etc. here)

Send My Quote Via

E-Mail	Fax
Call me by Phone!	Regular Mail

Thank you for filling out this form COMPLETELY!

You are applying for automobile insurance based on the information provided above as well as any information that may be available from reports ordered on your drivers license and auto insurance. This information may include a history of tickets, license suspensions, insurance claims, non-payments and cancellations. You authorize needcarinsurance.ca to collect and disclose information as permitted by law and required by insurance companies for the purposes necessary to assess your application for new or renewal automobile insurance, investigate and settle claims and detect and prevent fraud. You also agree that needcarinsurance.ca may collect and use this personal information to consider your on-going needs for insurance products and information. You understand that your personal information may be disclosed pursuant to any relevant privacy laws or other laws.

Yes, I Agree. Please Send Me an Auto Quote NOW!

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Absolute Insurance Brokers

12 Second Street

Orangeville, Ontario L9W 2B5

toll free 877-941-2266 / local tel. 519-941-2266

fax. 519-941-2267

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