J.B. Kelly Insurance Broker Ltd.
J.B. Kelly Insurance Broker Ltd.
"Professional friendly service for your peace of mind"
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Car Insurance
Home Insurance
Business Insurance
Farm Insurance
RV Insurance
Trailer Insurance
 
 
Quote Requests

Car Insurance
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Have you ever had insurance cancelled or refused?
Yes     No
If yes, why? :
Do you currently insure your car?
Yes     No
If not, have you had insurance for 12 consecutive months within the last 6 years?
Yes     No
When should coverage start? (dd/mm/yyyy)
   
Driver(s) Information:
#1 #2 #3
Name:
Date of Birth:
Drivers Licence #:
Years Licenced in Canada:
Licence Class:
Date of G1 Licensing (MM/YY):
Date of G2 Licensing (MM/YY):
Date of G Licensing (MM/YY):
Sex:
Marital Status:
Driving School:
If yes, date completed (MM/YY):
Retired?
Minor traffic convictions in the last 3 yrs:
If yes, what where they? :
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
If yes, what where they? :
Are you currently insured?
Yes     No
When does current insurance policy expire?:
If there is a lapse in insurance, how long will it be?:
Name of previous insurance company:
Have any of above drivers had their Licences suspended or lapsed in the past 6 years?
Yes     No
If yes, why? :
Have any of the drivers above had accidents or claims in the past 10 years?
Yes     No
   
Claims Information:
Claims Date (mm/yyyy) Driver involved
#1:
#2:
#3:
Please use this space to describe the claims filled in above:
   
Vehicle Information:
Vehicle #1 Vehicle #2
Vehicle Make:
Year:
Model:
Style:
Use:
KM driven one way to work:
Kilometres driven per year:
Who is primary driver:
   
Coverage Required:
Vehicle #1 Vehicle #2
Liability:
Collision Deductible:
Comprehensive Deductible:
Rental Car Coverage :
Accident Waiver Coverage :
 

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