Auto Insurance Quote - JW Davis Insurance Brokers

NAME(S) ON REGISTRATION:*
First Last
CONTACT #
TELEPHONE NUMBER:*
E-MAIL:*
ADDRESS WITH UNIT # (IF APPLICABLE):*
Street Address Address Line 2 City Province Postal Code
EFFECTIVE / RENEWAL DATE:*
YYYY slash MM slash DD
NAME OF CURRENT / LAST INSURANCE COMPANY AND POLICY # :*
NUMBER OF YEARS WITH CURRENT COMPANY:*

EXACT YEAR / MAKE / MODEL OF VEHICLE:*

(e.g. 2DR, 4DR, LE, SE, XLT, SINGLE CAB, TWIN CAB, 2WD, AWD)
IS VEHICLE LEASED OR FINANCED?
DATE VEHICLE WAS PURCHASED?*
YYYY slash MM slash DD
PURCHASE PRICE?*
Coverage
COVERAGES:*
COLLISION*
COMPREHENSIVE*
RENTAL CAR COVERAGE:
DO YOU USE YOUR VEHICLE TO CARPOOL?*
DO YOU PARTICIPATE IN ANY RIDESHARING PROGRAMS (SUCH AS UBER OR TURO)?*
DO YOU USE YOUR VEHICLE FOR: UBER EATS, SKIP THE DISHES, AMAZON, UBER DRIVE?*
USE OF VEHICLE:
NUMBER OF KMS ONE WAY:*
ANNUAL KMS:*
VIOLATIONS / TICKETS WITHIN LAST 3 YEARS?*
PLEASE GIVE DATES AND DETAILS*
ACCIDENTS / CLAIMS IN LAST 9 YEARS?
PLEASE GIVE DATES AND DETAILS, INCL NOT-AT-FAULT, THEFT OR WINDSHIELD CLAIMS*

Coverage