CLASSIC CARS

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Number of registered owner:
Owner #1
First name:
Last name:
Date of birth :
Number:
Appt:
Street:
City:
Postal code:
Province:
Since when have you lived at this address?
Email:
Home phone:
Work phone:
Cell phone:
Preferred contact time:
Preferred contact numbers?
Current situation?
Send me my quotes via text message (sms):
Owner #2
First name:
Last name:
Date of birth :
Number:
Appt:
Street:
City:
Postal code:
Province:
Since when have you lived at this address?
Email:
Home phone:
Work phone:
Cell phone:
Preferred contact time:
Preferred contact numbers?
Current situation?
Send me my quotes via text message (sms):

Informations
The reason for requesting a quote:
How did you hear about Assurance Confiance?
Policy effective date:
Home insurance renewal date (if applicable):
Current insurer:
Current annual premium:
How many years are you insured?
How many years have you been insured with this insurer?
Have you ever declared bankruptcy?
Are you released?
In the past 10 years, have you or anyone living with you been convicted of a criminal offence?
If so, explain why:
Do you allow access to your credit rating and accident history?

DRIVERS
Number of drivers
DRIVER #1

First name
Last name:
Date of birth:
Driving licence numbers:
Gender:
Marital Status:
Levels of education attained:
Occupation:
Employment field:
Employment:
Employer:
Do you allow the insurer to go check your information with the SAAQ?
Type of licence:
Have you completed a driver's training course?
At what age did you obtain a Driver's Licence?
How many times your licence been suspended in the last 6 years?
If so, explain why:
Number of tickets (convictions) within the last 3 years, excluding parking tickets?
If so, detail the violations:
How many consecutive years, have you been insured as a primary driver?
How many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?
If so, expand the reason:
Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?
Detailing the claim:
DRIVER #2

First name of the occasional Driver:
Last name of occasional drivers:
Date of birth:
Driver license number:
Sex:
Marital Status:
Levels of education attained:
Occupation:
Employment field:
Employment:
Employer:
Do you allow the insurer to go check your information with the SAAQ?
Type of licence:
Have you completed a driver's training course?
At what age did you obtain a Driver's Licence?
How many times your licence been suspended in the last 6 years?
If so, explain why:
Number of tickets (convictions) within the last 3 years, excluding parking tickets?
If so, detail the violations
How many consecutive years, have you been insured as a second driver?
How many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?
If so, expand the reason:
Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?
Detailing the claim:
DRIVER #3

First name of the third driver
Last name of the third driver
Date of birth:
Driver license number:
Sex:
Marital Status:
Levels of education attained:
Occupation:
Employment field:
Employment:
Employer:
Do you allow the insurer to go check your information with the SAAQ?
Type of licence:
Have you completed a driver's training course?
At what age did you obtain a Driver's Licence?
How many times your licence been suspended in the last 6 years?
If so, explain why:
Number of tickets (convictions) within the last 3 years, excluding parking tickets?
If so, detail the violations:
How many consecutive years, have you been insured as a driver?
How many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?
If so, expand the reason:
Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?
Detailing the claim:

Vehicle

Number of vehicles
Vehicle #1

Vehicle make:
Model:
Vehicle year:
Serial number:
Current value of the vehicle: (excluding taxes):
Do you have a vehicle evaluation?
If so, it dates from when?
Name of the Principal Driver:
Name of occasional drivers:
Name of young drivers:
Date of Purchase or lease:
Condition of vehicles on the possession date:
Vehicles financing:
If applicable, which is the creditor
Is the vehicle leased?
If applicable, which is the lessor:
Primary use of this vehicle:
Number of km travelled annually:
Number of km to get to work or school:
Number of Km for business year (if applicable):
Km radius of action for business (if applicable)?
Does the vehicle is storage?
If so, at what location?
During the period of use, where the vehicle is parked?
Use in a competition:
Has the vehicle been in a serious accident or rebuilt?
Is it currently insured with the new value?
Is it currently insured with the replacement value?
Is the vehicle used outside the province?
If used outside the province, how many consecutive days maximum?
Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?
If so, what value?
Is this vehicle currently uninsured for more than 10 days and insurers refuse to provide coverage?
Has the vehicle been modified for performance at greater than $1000?
If so, what value?
Has the appearance of the vehicle been modified at a cost greater than $1000?
If so, what value?
Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?
Startup Blockage Mechanism:
Tracking system:
Alarm:
Engraving:
Steering Blocking Bar:

Vehicle #2

Vehicles make:
Model:
Vehicle year
Serial number:
Current value of the vehicle: (excluding taxes):
Do you have a vehicle evaluation?
If so, it dates from when?
Name of the Principal Driver:
Name of occasional drivers:
Name of young drivers:
Date of Purchase or lease:
Condition of vehicles on the possession date:
Vehicles financing:
If applicable, which is the creditor
Is the vehicle leased?
If applicable, which is the lessor:
Primary use of this vehicle:
Number of km travelled annually:
Number of km to get to work or school:
Number of Km for business year (if applicable):
Km radius of action for business (if applicable)?
Does the vehicle is storage?
If so, at what location?
During the period of use, where the vehicle is parked?
Use in a competition:
Has the vehicle been in a serious accident or rebuilt?
Is it currently insured with the new value?
Is it currently insured with the replacement value?
Is the vehicle used outside the province?
If used outside the province, how many consecutive days maximum?
Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?
If so, what value?
Is this vehicle currently uninsured for more than 10 days and insurers refuse to provide coverage?
Has the vehicle been modified for performance at greater than $1000?
If so, what value?
Has the appearance of the vehicle been modified at a cost greater than $1000?
If so, what value?
Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?
Startup Blockage Mechanism:
Tracking system:
Alarm:
Engraving:
Steering Blocking Bar:

Vehicle #3

Vehicles make:
Model:
Vehicle year:
Serial number:
Current value of the vehicle: (excluding taxes):
Do you have a vehicle evaluation?
If so, it dates from when?
Name of the Principal Driver:
Name of occasional drivers:
Name of young drivers:
Date of Purchase or lease:
Condition of vehicles on the possession date:
Vehicles financing:
If applicable, which is the creditor
Is the vehicle leased?
If applicable, which is the lessor:
Primary use of this vehicle:
Number of km travelled annually:
Number of km to get to work or school:
Number of Km for business year (if applicable):
Km radius of action for business (if applicable)?
Does the vehicle is storage?
If so, at what location?
During the period of use, where the vehicle is parked?
Use in a competition:
Has the vehicle been in a serious accident or rebuilt?
Is it currently insured with the new value?
Is it currently insured with the replacement value?
Is the vehicle used outside the province?
If used outside the province, how many consecutive days maximum?
Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?
If so, what value?
Is this vehicle currently uninsured for more than 10 days and insurers refuse to provide coverage?
Has the vehicle been modified for performance at greater than $1000?
If so, what value?
Has the appearance of the vehicle been modified at a cost greater than $1000?
If so, what value?
Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?
Startup Blockage Mechanism:
Tracking system:
Alarm:
Engraving:
Steering Blocking Bar:

GUARANTEES

Vehicle #1

Liability:
Collision or upset deductible:
Comprehensive deductible:
# 2: Driving vehicles not designated
#20A: Travel costs (broad form) (Section B)
#27: Legal liability resulting from damage caused to vehicles of which named insured is not owner (including vehicles provided by an employer) (Section A)
#34: Accident benefit insurance: Death and dismemberment benefits
#43E: Total loss - Replacement cost
# 33: Insurance troubleshooting costs
Vehicle #2

Liability:
Collision or upset deductible:
Comprehensive deductible:
# 2: Driving vehicles not designated
#20A: Travel costs (broad form) (Section B)
#27: Legal liability resulting from damage caused to vehicles of which named insured is not owner (including vehicles provided by an employer) (Section A)
#34: Accident benefit insurance: Death and dismemberment benefits
#43E: Total loss - Replacement cost
# 33: Insurance troubleshooting costs
Vehicle #3

Liability:
Collision or upset deductible:
Comprehensive deductible:
# 2: Driving vehicles not designated
#20A: Travel costs (broad form) (Section B)
#27: Legal liability resulting from damage caused to vehicles of which named insured is not owner (including vehicles provided by an employer) (Section A)
#34: Accident benefit insurance: Death and dismemberment benefits
#43E: Total loss - Replacement cost
# 33: Insurance troubleshooting costs
ADDITIONAL NOTES