V.B. Insurance Brokers Ltd.
St. Paul, Alberta
780-645-4449

Request for Automobile
Insurance Quotation

Offered ONLY to Residents of Alberta

Important: Please be accurate in completing this form. Your quotation will be based on the information you give us today. If these facts change, your rate will be subject to adjustment.

Information requested below is used by this brokerage to develop a prospect profile, and may or may not be used in the pricing of any estimated policy premiums.

Personal Information

   First Name:                
   Last Name:                 
   E-Mail:                    
   Address:                   
   City/Town:                 
   Province:                  
   Postal Code:               
   Home Telephone:            
   Business Telephone:        
   Fax Number:                
   Occupation:                
   Annual Income:            $
   Do you have an Employee Group Benefits Plan?            YesNo





Vehicle Information




The Vehicle Identification Number listed on your vehicle ownership, your current insurance policy, or located on the lower right portion 

of the front windshield may entitle you to special discounts.




   Vehicle Identification Number: 
   Registered Owner: First Name   
                   : Last name    
   Year:                           (yyyy)
   Make:  (Ford etc.)                
   Model: (Taurus etc.)           
   BODY: (2 dr. etc.)             
   2WD or 4WD?                    2WD 4WD







Usage Information




   Annual Kilometres:            
      (expected this year)
   Daily Km. one way             
      (To/From work, school, commuter point)
   Anti-Theft Device?            Yes No


If you leave the country for extended periods of time and take your vehicle with you, please show number of months out of the country:  

Check the boxes following to indicate use of vehicle:

     Pleasure     Business      Commute  


If you selected $quot;business" please

 describe the type of business and any cargo carried.

   



Current Policy Information

        Insurance Company:           
        Policy Number:               
        Policy Expiry Date:           (mm/dd/yyyy)






Driver Information



Driver's licence numbers may be significant to the underwriting accuracy and will speed the return of your quote.



   Driver's First Name:            
             Last Name:            
   Driver's Licence Number:        
   Relation to Applicant:          
   Date of Birth:                   (mm/dd/yyyy)
   Sex:                            Female Male
   Date First Licenced in Canada?   (mm/dd/yyyy)
   Occupation:                     

   Married?                                                 YesNo
   Driver Training?                                         YesNo
   Do you hold a current license valid in another country?  YesNo






Indicate which years, starting from the present, driver has been insured in the last six years.


                 This     --------- prior years ---------
                 Year       (most recent to the left)
                                           



Indicate if driver has had insurance cancelled and for what reason:

              Nonpayment        Fraud      Misrepresentation

                                            






Claims Information



Please check the following, if applicable:


    Any claims or accidents in the last 6 years?
    Any convictions, fines or traffic violations in the last 3 years?
    Any losses due to theft, vandalism or other comprehensive
      claims in the last 6 years?
    Any licence suspensions in the past 6 years?



1. List the two most recent claims or accidents in the past six years.


Claim 1


      Date:                      (mm/dd/yyyy)
      Was this driver at fault?                             YesNo
      Did your insurance company pay out on the claim?      YesNo
      If yes, how much was paid out on the claim (if known)?
                 Own car:     $ 
                 Other car:   $ 
      List details of accident
     





Claim 2


      Date:                      (mm/dd/yyyy)
      Was this driver at fault?                             YesNo
      Did your insurance company pay out on the claim?      YesNo
      If yes, how much was paid out on the claim (if known)?
                 Own car:     $ 
                 Other car:   $ 
      List details of accident
     



Are there more than two claims?

      No
      Yes. List details of all claims in the last six years
              in free form including: 
                 was this driver at fault, 
                 date of claim, (mm/dd/yyyy)
                 details of accident,
                 did your insurance company pay out on the claim,
                         if so, how much (if known) on your car and
                         on the other car.

      




2. List losses due to theft, vandalism or other comprehensive claims in the past 6 years.



         Date                   Details
       (mm/yyyy)
      




3. List convictions, fines for traffic violations in the past 3 years.



         Date         Type of Conviction
       (mm/yyyy)       (e.g speeding, stop sign violation
                            Do not include parking & seat belt violations)
      




4. State if driver's licence has been suspended or revoked in the past 6 years.



        Date     How Long      Reason
      (mm/yyyy)  (Months)
      






Coverage Required


Mandatory Coverage

Liability - Please select the amount.


      



Statutory Coverage:
      

      
1. Accident Benefits
      
2. Family Protection Endorsement
      

   


Loss or Damage Deductible - Please select the amount.

Comprehensive (excluding Collision or Upset)




      



Collision or Upset



      


Do you require coverage for Loss of Use? - Please select Yes/No.

      





Please check that you have supplied all information requested.


Every question on each Request for Quotation is important. Please complete each section in full, so that all your applicable discounts can be determined.



















Last modified on March 17, 1999 by 
VB Insurance Brokers Ltd.