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Name: _____________________________________________________

E-Mail address: _____________________________________________

Address:___________________________________________________

___________________________________________________________

City:   _______________ State/Province:_______ Postal Code: _________

Phone(Home) ___________  (Cell) ___________ (Work) ____________

Driver's License #:_____________________ State/Province: ________

Coverage Start: _____/_____/_____        End: _____/_____/_____

Vehicle ID Number (VIN): _____________________________________

Vehicle Year:________ Make: __________________________________

Model: _____________________________ Value (US$) _____________

Towed Unit Year:_______ Make: _______________________________

Model: _____________________________ Value (US$) _____________

Auto Insurer:________________________ Plate #: _________________

Policy #: _______________________ Expiry Date: _____/_____/______

Do you carry Collision & Theft Cover in Canada? 

(      )  Yes  /  (      )  No.   

Drivers under 21?  (       ) Yes  /  (        )  No.

Lien holder: _________________________________________________

Address: ___________________________________________________

Account No: _________________________________________________

 Current Exchange Rates

Cover                             Limit(US$)                     Premium($US)

_____________  ___________________ ____________________

_____________  ___________________ ____________________

_____________  ___________________ ____________________

_____________  ___________________ ____________________

                                     Premium Tax ____________________

                                             Policy fee(s) ____________________

Total (Approx. $CDN): ________ = 1.55* ____________________

Credit Card: ____________________  Expiry: _____/_____/_____

Credit Card #: _______________________________________

 

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Last modified: 02/25/02