SurNet Insurance Group Inc. Barrie, Ontario

Primary Operator Information

Full Name

Email

Phone

Age

Years Licensed G1

G2

G

M1

M2

M

Driver Training Certificate

Are you presently insured?

Additional Drivers

Are there any additional drivers in your household?

Insurance History

Any claims in the past 10 years?

Any policy cancellations in the past 3 years?

Any tickets in the past 3 years?

Any license suspensions in the past 10 years?

Vehicle #1

Year

Make

Model

Primary Operator

Vehicle Use

How many KM do you commute one way?

Liability

Collision

Comprehensive

Accident Forgiveness

Loss of use/rental car

Waiver of Depreciation

Vehicle #2 (Optional)