Joseph Kovacs Insurance Brokers- Auto Quote Form

Kovacs Insurance

AUTO INSURANCE
QUOTE FORM

To receive a quote for auto insurance please complete the following form:

"Serving Strathroy and Area"

Contact Information:

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

Insurance Information:

(Please provide V.I.N. as there may be several variations of vehicle model.)

(If V.I.N. is not supplied, you will need to contact us.)

Year of vehicle 1:
Make/Model:
V.I.N.

Year of vehicle 2:
Make/Model:
V.I.N.

(The following is required (unless NONE) and may be used to collect past claims information)

Name of most recent 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 one way?	kms.
How many kilometres do you drive per year?	kms.

Is your vehicle used for any of the following? (check all that apply)

Business

Pleasure

Farming

List of Drivers:

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

*	If Date of Birth is after 1978/04/01 then you must provide the following information;
	G1 - Date Licensed:
	G2 - Date Licensed:
	G - Date Licensed:
Occasional Driver (#2)
Name	Date of Birth (yy/mm/dd)	Years Licensed	License Class

*	If Date of Birth is after 1978/04/01 then you must provide the following information;
	G1 - Date Licensed:
	G2 - Date Licensed:
	G - Date Licensed:

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

*	If Date of Birth is after 1978/04/01 then you must provide the following information;
	G1 - Date Licensed:
	G2 - Date Licensed:
	G - Date Licensed:

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

Any traffic violations in the past 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

If yes, then the date and reason must be given below:

Coverages: (Enter nil if not required):

NOTE: In the best interest of our clients, we do not offer liability coverage less than $1,000,000.

Liability Limit:	Collision Deductible:	Comprehensive Deductible:

When should we contact you?:

How should we contact you?

E-mail Phone Fax Mail

Thank you for filling out our online quote. Please allow a few days for a response. You can now hit the submit button below to send the information or the reset button to clear the form.

JOSEPH KOVACS INSURANCE LIMITED
48 Front St. E., P.O. Box 7 Strathroy, Ontario N7G 3J

HOME I QUOTES I LINKS I EMAIL