Quotes - Leibel MacMillan Insurance

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Name:
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
Age of principal driver:
Marital status of principal driver:
Number of years licensed for principal driver:
Gender of additional drivers under 25 years of age:
Do driver(s) under 25 years of age have driver training certification?	Yes No
Any driving convictions in past 3 years?	Yes No
If so (# of convictions):
Do you use your vehicle for business?	Yes No
Do you use your vehicle to commute to and from work?	Yes No
Year, make and model of vehicle:
Liability limit requested:
Coverage Preferred:
Deductible:
Additional vehicles to be quoted?	Yes No

How many years have you consistently had an auto policy in force or been listed on someone else’s policy as a listed driver?*
Number of at fault claims in the past 10 years?*
How many years since last at fault claim (if within 10 years)*
How many years since last claim? (if within 10 years)*
What is your occupation?*
How many kilometers do you commute to work 1 way?*
Was your prior policy canceled for non payment?*
Was your policy lapsed for any other reason by the insurance company?*
Which insurance company has your current property insurance?*