Overview Auto Insurance Property Insurance Boat Insurance Motor Home Insurance Travel Trailer Insurance Retail/Store Packages Travel Insurance       Motor Home Insurance Name: Address: City: Province: Postal Code: Phone Number: Email Address: Have you ever had insurance cancelled or refused? Yes     No Do you currently insure your Motor Home? Yes     No How many years have you had a continuous insurance policy? When should coverage start? (dd/mm/yyyy) Driver(s) Information: #1 #2 #3 Name: Age: Years licensed in Canada: License class: 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Sex: Male Female Male Female Male Female Marital status: Married Single Common-law Married Single Common-law Married Single Common-law Driving school: Yes No Yes No Yes No Retired? Yes No Yes No Yes No Minor traffic convictions in the last 3 yrs: 0 1 2 3 More than 3 0 1 2 3 More than 3 0 1 2 3 More than 3 Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.): 0 1 2 3 More than 3 0 1 2 3 More than 3 0 1 2 3 More than 3 Have any of above drivers had their licenses suspended or revoked in the past 3 years? Yes     No Have any of the drivers above had accidents or insurance in the past 6 years? Yes     No Claims Information: Claims Date (mm/yyyy) Driver involved #1: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3 #2: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3 #3: N/A At-fault accident Not-at-fault accident Partial at-fault accident Windshield/vandalism/theft N/A Driver #1 Driver #2 Driver #3     Vehicle Information:   Vehicle make: Year: Model: Style: 2-door 2-door hatch 4-door 4-door hatch Wagon SUV Pick up Van Use: Pleasure Commute under 5km Commute 6-15km Commute 16-25km Commute 26+ km Partial business Business Kilometres driven per year: 0-5000 5001-10000 10001-15000 15001-20000 20001-25000 over 25000 Who is primary driver: N/A Driver #1 Driver #2 Driver #3     Coverage Required:   Liability: 200,000 500,000 1,000,000 2,000,000 Collision deductible: 250 500 1,000 Comprehensive deductible: 250 500 1,000       Disclaimer