Auto Insurance


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Note: Only available to residents of New Brunswick

Name:
Address:
City:
Province:

Postal Code:

Phone Number:
Have you ever had insurance cancelled or refused? Yes No
Have you had consecutive insurance for the last 6 years? Yes No
Expiry date of your current policy if applicable (dd/mm/yyyy):

 

Driver Information #1              #2    #3
Name of driver      
Date of Birth    
Years licensed in Canada   
Marital status:
Driver training:  
(if first licensed less than 6 years ago)

Yes
No

 Yes
No		 Yes
No
Retired:    Yes
No		 Yes
No		 Yes
No
Minor traffic convictions in the last 3 years:                                  
(Speeding, stop sign, failing to signal, etc.)
Major traffic convictions in the last 3 years:                                                   
(Impaired or careless driving, driving while under suspension, etc)

 

Have any of the above drivers had their licenses
suspended or lapsed in the past 6 years? Yes No

 

Have any of the above drivers had accidents
or claims in the past 6 years: Yes No

 

 

Claims information:

 Claims  Date(mm/yyyy) Driver
#1
#2 
#3 

                                                  

  

Vehicle Information:   Vehicle #1  Vehicle #2
Vehicle make:  
Year:   
Model: 
Style: 
Serial Number (if available):
Primary Use:
Km driven one way to work:
Km driven per year:
Who is the primary driver:
Coverage required or current coverage: Vehicle #1    Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:

                                

I give my consent for Kent and White Insurance to use this information for the purpose of obtaining an accurate insurance quote. This information will not be used, or shared with any other parties, for any reason other than obtaining an accurate insurance quote.
I accept
I do not accept

 




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