Manual High Risk Auto Insurance Quote Form

Pre-Requisite Questions
Are you currently a resident of Ontario Canada?*
- Yes
- No
Sorry, you must be a resident of Ontario Canada to apply for a quote.

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Will the vehicle now, or in the future be used for Uber driving?*
- Yes
- No
Sorry, we cannot provide insurance for vehicles used for Uber driving.

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Is the vehicle you wish to insure over 20 years old?*
- No
- Yes
Sorry, we cannot insure vehicles over 20 years of age.

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How many vehicles require insurance?*
- One
- Two
- Three +
Sorry, this form can only accept up to two vehicles. We can still provide you a quote by telephone. Please call our office directly 1.877.373.3133.

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How many drivers will you list?*
- One (Applicant is Driver #1)
- Two (Referred to as Driver #2)
- Three (Referred to as Driver #3)
- Four +
Drivers include anyone over the age of 16 that live in the same household who DO NOT have their own auto insurance.
Sorry, this form can only accept up to two vehicles and three drivers. We can still provide you a quote by telephone. Please call our office directly 1.877.373.3133.

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Applicant Information (Driver #1)
Name*
First Last
Gender*
- Male
- Female
Street Address*
City*
Postal Code*
Phone*
Email*
Enter Email Confirm Email

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Vehicle #1 Information
Year*
Make*
Model*
17 Digit VIN #
Purchase Month*
Purchase Year*
Type of coverage*
KMs driven to work/school (One Way)*
KMs driven overall (Yearly)*

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Vehicle #2 Information
Year*
Make*
Model*
17 Digit VIN #
Purchase Month*
Purchase Year*
Type of coverage*
KMs driven to work/school (One Way)*
KMs driven overall (Yearly)*

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Applicant (Driver #1) Information
Birth Day*
Birth Month*
Birth Year*
Applicant: Status*
Applicant: Did you acquire your license prior to 1994?*
Applicant: Month G license was obtained*
Applicant: Year G license was obtained*
Applicant: Month G license was obtained (Optional)
Applicant: Year G license was obtained (Optional)
Applicant: Month G2 license was obtained*
Applicant: Year G2 license was obtained*
Applicant: Month G1 license was obtained*
Applicant: Year G1 license was obtained*
Applicant: Did you take certified driver training?*
Applicant: How many years of CONTINUOUS insurance have you held in the past 15 years?*
Applicant: Current Insurance Status*
Applicant: Why are you un-insured?*
Applicant: What is the Expiry Date of your current or last policy?*
MM slash DD slash YYYY

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Applicant (Driver #1) Driving History
Applicant: How many AT FAULT accidents in past 6 years?*
Date of Accident #1*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #2*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #3*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #4*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.

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Applicant: How many TICKETS in the past 3 years?*
Date of Conviction #1*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #1*
Date of Conviction #2*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #2*
Date of Conviction #3*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #3*
Date of Conviction #4*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #4*
Date of Conviction #5*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #5*
Date of Conviction #6*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #6*
Date of Conviction #7*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #7*

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Applicant: In the past 6 years, how many times has your license been suspended for OVER 30 days?*
Reason for Suspension #1*
Date of Suspension #1*
DD slash MM slash YYYY
Date of Reinstatement #1*
DD slash MM slash YYYY
Reason for Suspension #2*
Date of Suspension #2*
DD slash MM slash YYYY
Date of Reinstatement #2*
DD slash MM slash YYYY
Reason for Suspension #3*
Date of Suspension #3*
DD slash MM slash YYYY
Date of Reinstatement #3*
DD slash MM slash YYYY

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Applicant: How many times has your policy been cancelled for NON-PAYMENT in the past 3 years?*
Date of 1st Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of 2nd Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of 3rd Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.

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Applicant: Have you ever been cancelled for NON-DISCLOSURE or MIS-REPRESENTATION?*

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Driver #2 Information
Driver #2: Name*
First Last
Driver #2: Gender*
- Male
- Female
Birth Day*
Birth Month*
Birth Year*
Driver #2: Status*
Driver #2: Acquire license prior to 1994?*
Driver #2: Month G license was obtained*
Driver #2: Year G license was obtained*
Driver #2: Month G license was obtained (Optional)
Driver #2: Year G license was obtained (Optional)
Driver #2: Month G2 license was obtained*
Driver #2: Year G2 license was obtained*
Driver #2: Month G1 license was obtained*
Driver #2: Year G1 license was obtained*
Driver #2: Take certified driver training?*
Driver #2 How many years of CONTINUOUS insurance held in the past 15 years?*
Driver #2: Current Insurance Status*
Driver #2: Why un-insured?*
Driver #2: What is the Expiry Date of your current or last policy?*
MM slash DD slash YYYY

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Driver #2: Driving History
Driver #2: How many AT FAULT accidents in past 6 years?*
Date of Accident #1*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #2*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #3*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #4*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.

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Driver #2: How many TICKETS in the past 3 years?*
Date of Conviction #1*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #1*
Date of Conviction #2*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #2*
Date of Conviction #3*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #3*
Date of Conviction #4*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #4*
Date of Conviction #5*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #5*
Date of Conviction #6*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #6*
Date of Conviction #7*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #7*

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Driver #2: In the past 6 years, how many times has license been suspended for OVER 30 days?*
Reason for Suspension #1*
Date of Suspension #1*
DD slash MM slash YYYY
Date of Reinstatement #1*
DD slash MM slash YYYY
Reason for Suspension #2*
Date of Suspension #2*
DD slash MM slash YYYY
Date of Reinstatement #2*
DD slash MM slash YYYY
Reason for Suspension #3*
Date of Suspension #3*
DD slash MM slash YYYY
Date of Reinstatement #3*
DD slash MM slash YYYY

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Driver #2: How many times has policy been cancelled for NON-PAYMENT in the past 3 years?*
Date of 1st Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of 2nd Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of 3rd Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.

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Driver #2: Have you ever been cancelled for NON-DISCLOSURE or MIS-REPRESENTATION?*

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Driver #3 Information
Driver #3: Name*
First Last
Driver #3: Gender*
- Male
- Female
Birth Day*
Birth Month*
Birth Year*
Driver #3: Status*
Driver #3: Acquire license prior to 1994?*
Driver #3: Month G license was obtained*
Driver #3: Year G license was obtained*
Driver #3: Month G license was obtained (Optional)
Driver #3: Year G license was obtained (Optional)
Driver #3: Month G2 license was obtained*
Driver #3: Year G2 license was obtained*
Driver #3: Month G1 license was obtained*
Driver #3: Year G1 license was obtained*
Driver #3: Take certified driver training?*
Driver #3: How many years of CONTINUOUS insurance held in the past 15 years?*
Driver #3: Current Insurance Status*
Driver #3: Why un-insured?*
Driver #3: What is the Expiry Date of your current or last policy?*
MM slash DD slash YYYY

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Driver #3: Driving History
Driver #3: How many AT FAULT accidents in past 6 years?*
Date of Accident #1*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #2*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #3*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of Accident #4*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.

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Driver #3: How many TICKETS in the past 3 years?*
Date of Conviction #1*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #1*
Date of Conviction #2*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #2*
Date of Conviction #3*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #3*
Date of Conviction #4*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #4*
Date of Conviction #5*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #5*
Date of Conviction #6*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #6*
Date of Conviction #7*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Reason Ticket #7*

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Driver #3: In the past 6 years, how many times has license been suspended for OVER 30 days?*
Reason for Suspension #1*
Date of Suspension #1*
DD slash MM slash YYYY
Date of Reinstatement #1*
DD slash MM slash YYYY
Reason for Suspension #2*
Date of Suspension #2*
DD slash MM slash YYYY
Date of Reinstatement #2*
DD slash MM slash YYYY
Reason for Suspension #3*
Date of Suspension #3*
DD slash MM slash YYYY
Date of Reinstatement #3*
DD slash MM slash YYYY

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Driver #3: How many times has policy been cancelled for NON-PAYMENT in the past 3 years?*
Date of 1st Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of 2nd Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.
Date of 3rd Cancellation*
DD slash MM slash YYYY

Enter 1st day of the month if unsure of the exact date.

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Driver #3: Have you ever been cancelled for NON-DISCLOSURE or MIS-REPRESENTATION?*

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How did you hear about us?*
Phew ... all done!
Do you have any additional comments or notes you'd like to add to your submission?
Please let us know if you have any additional information or comments.

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Pre-Requisite Questions

Sorry, you must be a resident of Ontario Canada to apply for a quote.

Sorry, we cannot provide insurance for vehicles used for Uber driving.

Sorry, we cannot insure vehicles over 20 years of age.

Sorry, this form can only accept up to two vehicles. We can still provide you a quote by telephone. Please call our office directly 1.877.373.3133.

Sorry, this form can only accept up to two vehicles and three drivers. We can still provide you a quote by telephone. Please call our office directly 1.877.373.3133.

Applicant Information (Driver #1)

Vehicle #1 Information

Vehicle #2 Information

Applicant (Driver #1) Information

Applicant (Driver #1) Driving History

Driver #2 Information

Driver #2: Driving History

Driver #3 Information

Driver #3: Driving History

Phew ... all done!