Auto Insurance Quote February 15, 2016by jarekn Auto Quote Step 1 of 4 25% NAME(S) ON REGISTRATION:* First Last CONTACT #TELEPHONE NUMBER:*E-MAIL:* ADDRESS WITH UNIT # (IF APPLICABLE):* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code EFFECTIVE / RENEWAL DATE:* Date Format: YYYY slash MM slash DD NAME OF CURRENT / LAST INSURANCE COMPANY AND POLICY # :*NUMBER OF YEARS WITH CURRENT COMPANY:* CANCELLED FOR NON-PAYMENT IN LAST 3 YEARS?*YESNODATE:* Date Format: YYYY slash MM slash DD SUSPENDED / LOST LICENSE IN LAST 6 YEARS?*YESNODATE:* Date Format: YYYY slash MM slash DD MONTHS*MARITAL STATUS:*SINGLECOMMON-LAWMARRIED/WIDOWEDDIVORCED/SEPARATEDDATE OF BIRTH:* Date Format: YYYY slash MM slash DD DATE OF LICENSE:*G1 (MM/YYYY)G2 (MM/YYYY)G (MM/YYYY)DRIVERS TRAINING WITHIN LAST 3 YEARS?*YESNODATE:* Date Format: YYYY slash MM slash DD EXACT YEAR / MAKE / MODEL OF VEHICLE:*(e.g. 2DR, 4DR, LE, SE, XLT, SINGLE CAB, TWIN CAB, 2WD, AWD)IS VEHICLE LEASED OR FINANCED?YESNODATE VEHICLE WAS PURCHASED?* Date Format: YYYY slash MM slash DD PURCHASE PRICE?*CoverageCOVERAGES:*$1,000,000$2,000,000 LIABILITYCOLLISION*$0$500$1000$1500$2000$2500COMPREHENSIVE*$0$500$1000$1500$2000$2500RENTAL CAR COVERAGE:YESNODO YOU USE YOUR VEHICLE TO CARPOOL?*YESNODO YOU PARTICIPATE IN ANY RIDESHARING PROGRAMS (SUCH AS UBER OR TURO)?*YESNODO YOU USE YOUR VEHICLE FOR: UBER EATS, SKIP THE DISHES, AMAZON, UBER DRIVE?*YESNOUSE OF VEHICLE:PLEASURE ONLYCOMMUTINGBUSINESSNUMBER OF KMS ONE WAY:*ANNUAL KMS:*VIOLATIONS / TICKETS WITHIN LAST 3 YEARS?*YESNOPLEASE GIVE DATES AND DETAILS*ACCIDENTS / CLAIMS IN LAST 9 YEARS?Please selectYESNOPLEASE GIVE DATES AND DETAILS, INCL NOT-AT-FAULT, THEFT OR WINDSHIELD CLAIMS* ARE YOU INTERESTED IN A HOME/CONDO/TENANT QUOTE?*Please selectYESNOTHE HOME / APARTMENT INSURED WITH THE SAME CARRIER?*YESNOWHAT IS THE NAME OF THE HOME CARRIER?*FULL NAME OF PERSON OR ORGANIZATION WHO REFERRED J. W. DAVIS INSURANCE BROKERS?NOTES: