Slessor & Periard Insurance Limited

Name:
Address:
City:
Province:
Postal Code (X1Y 2Z3):
Phone Number (123-456-7890):
Email Address:
Age of principal driver:
Marital status of principal driver:
Number of years licensed for principal driver:
Gender of additional drivers under 25 years of age:
Do driver(s) under 25 years of age have driver training certification:	YesNo
Any driving convictions in past 3 years:	YesNo
If so (# of convictions):
Do you use your vehicle for business:	YesNo
Do you use your vehicle to commute to and from work:	YesNo
Year, make, and model of vehicle:
Liability limit requested:
Coverage Preferred:
Deductible:
Additional vehicles to be quotes:	YesNo
How many years have you consistently had an auto policy in force or been listed on someone else’s policy as a listed driver:
Number of at fault claims in the past 10 years:
How many years since last at fault claim (if within 10 years):
How many years since last claim? (if within 10 years):
What is your occupation:
How many kilometers do you commute to work 1 way:
Was your prior policy canceled for non payment:	YesNo
Was your policy lapsed for any other reason by the insurance company:
Which insurance company has your current property insurance:

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