Commercial Auto Insurance

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Applicant's full name*

Applicant’s full address: *

Contact number:*

Email address: *

Renewal date: *

Current insurance company:*

Description of operations:

Describe commodities carried:

RANGE OF OPERATION

Normal radius (kms):

Maximum radius (kms):

Any out of province use:

YES NO

YES NO

Average # of customers’ locations visited in a work day:

Is the vehicle also used for pleasure:

YES NO

Describe machinery or equipment mounted on or attached to vehicles:

Any special or seasonal use:

YES NO
- If yes, please describe usage (e.g. snow removal, road salting):

VEHICLE INFORMATION

Model year:
Make / model:

New cost
including equipment:

Vehicle identification
# (VIN / Serial No.):

Address where garaged:

DRIVER INFORMATION

Driver name:


License number:


Date of birth:


Date first licensed:


Current license class:

Date current class obtained:

Driver training certificate:

Convictions:

- If yes, what is the conviction date:


- If yes, please describe:


Claims / losses:

- If yes, what is the date of loss:

- If yes, please describe: