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Classic Car Insurance
Name:
Address:
City:
Province:
Postal Code:
(X1Y 2Z3)
Phone Number:
(123-456-7890)
Email Address:
(xxx@yyyy.zzz)
Age of principal driver:
Marital status of principal driver:
Married
Single
Number of years licensed
for principal driver:
Gender of additional drivers under 25 years of age:
Male
Female
N/A
Do driver(s) under 25 years of age have driver training certification?
Yes
No
Any at fault accidents
in past 6 years?
Yes
No
Any driving convictions
in past 3 years?
Yes
No
Do you use your vehicle
for business?
Yes
No
Do you use your vehicle to commute to and from work?
Yes
No
Year, make and model of vehicle:
Liability limit requested:
$200,000
$500,000
$1,000,000
$2,000,000
Coverage Preferred:
All perils
Collision
Comprehensive
Specified perils
Deductible:
$100
$250
$500
$1,000
Additional vehicles to be quoted?
Yes
No
Comments:
