Henry Equestrian Insurance Brokers
download printable version For manual submission, download this form here.
 

APPLICATION FOR AUTOMOBILE INSURANCE
TO BE COMPLETED AND SIGNED BY THE INSURED. ALL VALUES ARE SUBJECT TO REVIEW BY UNDERWRITING.
 
NAME OF OWNER(S)*:
STREET ADDRESS*:
CITY*:
POSTAL CODE*:
PROVINCE*:
BUSINESS PHONE NUMBER:
HOME PHONE NUMBER*:
FAX:
EMAIL ADDRESS *:
  APPLICANT SPOUSE
AGE:
SEX:          
DRIVER'S LICENSE #:
DATE LICENSED WITH    
        G2
        G
        OTHER    
DID YOU PASS YOUNG DRIVERS TRAINING          
        date passed
HAVE YOU AND YOUR SPOUSE BEEN CONTINUOUSLY INSURED FOR THE PAST 6 YEARS      Yes      No
    If not, how many years?
CURRENT OR PREVIOUS INSURANCE COMPANY
    name - policy number - expiry date     
HAVE YOU EVER BEEN CANCELLED FOR "NON-PAYMENT"     Yes     No
HAVE YOU OR YOUR SPOUSE HAD ANY ACCIDENTS IN THE PAST 6 YEARS      Yes      No
    At-fault? Give details
    Not at-fault? Give details
HAVE YOU HAD ANY COMPREHENSIVE LOSSES IN THE PAST 6 YEARS (e.g. windshield, vandalism, theft)     Yes      No
    If Yes, give details
HAVE YOU OR YOUR SPOUSE HAD ANY CONVICTIONS IN THE PAST 3 YEARS?      Yes      No
    If Yes, give details / dates
HAS YOUR LICENSE OR YOUR SPOUSE'S LICENSE BEEN SUSPENDED IN THE PAST 6 YEARS?     Yes     No
    If Yes, please advise why and for how long
  YEAR MAKE MODEL BODY CODE VIN
VEHICLE #1
  VEHICLE #1 VEHICLE #2 VEHICLE #3
USE (pleasure, commute, business, farm)
ANNUAL MILEAGE
If you commute, how far is it one way to work/school?
COVERAGES REQUIRED
Liability
Basic Accident Benefits
    NOTE* Optional Increase Benefits Available
Collision Deductible
Comprehensive Deductible
Protection Plus Yes No Yes No Yes No
Loss of Use (OEF 20) Yes No Yes No Yes No
Waiver of Depreciation (new vehicles only) Yes No Yes No Yes No
ANY OTHER DRIVERS? Yes No      If Yes, please provide the following information:
Name / Age / Sex / Relationship to you
How long have they been licensed in Canada?
Young Drivers Training? Yes No
Any at-fault accidents in the past 6 years? Yes No      If so, give details:
Any not-at-fault accidents in the past 6 years? Yes No      If so, give details:
Any comprehensive losses (e.g. windshield, vandalism, theft)? Yes No      If so, give details:
Any convictions in the past 3 years? Yes No      If so, give details:
Has their license been suspended in the past 6 years? Yes No      If so, please advise why and for how long:
Current or previous insurance company (name - policy number - expiry date):
 
SIGNATURE (ENTER YOUR NAME)*: date signed
D M YEAR