Auto Form – Risk Care General Insurance

Auto Insurance

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Name*

Date of Birth

Address

Phone*

Current Insurance Company

Renewal Date

Is your current insurance company cancelling you, reason

No of Vehicles in Household

No. of Drivers in Household

Year/Make/Model

Year/Make/Model 1

Single Line

Single Line1

Single Line2

Single Line3

Year/Make/Model1

Single Line4

Single Line5

Single Line6

Single Line7

Year/ Make/ Model /Vin No

Pur. Date

Pur. Price

Kms at Pur.

Leased/ Financed/ Owned

Owner/ Driver

one

1 Way Kms

Annual Kms

Pleasure Use / Business Use %

Winter Tires

Parking at night

Deductible with current insurance company

Attach Copy

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DRIVER INFO.

Number of drivers in the household

Number of licenced members in the household

Name

Driver Lic #

Relationship

Married/ Single

D/O/B

Occupation

Attach Ownership Copy (Driver 1)

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Attach Ownership Copy (Driver 2)

Upload

Attach Ownership Copy (Driver 3)

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Attach Ownership Copy (Driver 4)

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LICENCE INFO:

Driver Training (within last three years)

Attach Driver Training Certificate

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ACCIDENTS/ CLAIMS IN 9YRS:

Date

Driver Name

Vehicle

Description

At Fault/ Not Fault

Amt. Claimed

CONVICTIONS IN 3 YRS:

Date

Driver Name

Description

Exceeding Kms if Speeding

INSURANCE INFO:

First Time Insured

Date Insured with Current Company

Insurance Gap (From – To) Reason

License/ Vehicle Permit Cancelled/ Suspended for any driver in last 6yrs: Dates From -To:

Insurance canceled by any insurance company in last 3yrs, including for non payment. When & Why:

Cancelled for non-payment more than once in the last four years:

Add Void Cheque Copy

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Upload Previous Policy Document

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