Gray Insurance Brokers Inc.

Personal Information

Name:
Street Address:
City:
Postal Code:
Phone Number:
Fax Number:
E-mail Address:

Current Insurance Information

Year of 1st Vehicle:
Make/Model:
Vehicle Identification Number:
Additional Vehicles
Year of 2nd Vehicle:
Make/Model:
Vehicle Identification Number:
The following information may be used to access past claims information.
Current Insurance Company:
Policy Number:
Expiry Date:

Do you own your home?	Yes No
Do you drive your car to work?	Yes No
If yes, how far is it one way?	kms.
How many kilometres do you drive per year?	kms.

Do you use your vehicle for any of the following?

Business

Pleasure

Farming

Current Drivers of Vehicles

Registered Owner (#1)
Name	Date of Birth (yy/mm/dd)	Years Licensed	License Class

Occasional Driver (#2)
Name	Date of Birth (yy/mm/dd)	Years Licensed	License Class

Occasional Driver (#3)
Name	Date of Birth (yy/mm/dd)	Years Licensed	License Class

Drivers Under 25 Years of Age
Driver Under 25 (#1)	Dates License Issued
Name	Date of G1 (yy/mm/dd)	Date of G2	Date of G

	Driver Training?:	Yes No
Driver Under 25 (#2)
Name	Date of G1 (yy/mm/dd)	Date of G2	Date of G

	Driver Training?:	Yes No

Have you had any insurance claims in last 6 years?

Driver #	Date (yy/mm/dd)	Type of Claim	At Fault?
		Other:	Yes No
		Other:	Yes No
		Other:	Yes No

Has your insurance ever been cancelled for non-payment?	Yes No
If yes, when;

Have you had any traffic violations in the past three (3) years?

Driver #	Date (yy/mm/dd)	Type of Violation

Have any of the drivers had their drivers license suspended the past 6 years?
Yes No

Driver Name	Date (yy/mm/dd)	Reason and Date Re-Instated

Coverage Required

Liability Limit:	Collision Deductible:	Comprehensive Deductible:

Do you require any Additional Endorsements?

OPCF 44 - Yes No
OPCF 43 - Yes No
OPCF 27 - Yes No
OPCF 20 - Yes No

How should we contact you?

E-mail Phone Fax Regular Mail

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