H.L. Staebler Company Limited
The Best Insurance Is An Insurance Broker
 
QUOTE REQUESTS  
Car Insurance
Mandatory Fields are marked with *
Name*:
Email Address:
Address:
City:
Province:
Postal Code*:
Phone Number*:
Age of principal driver*:
Marital status of principal driver:
Enter years licensed*: (Enter at least one of the following)
 
G   /   / 
  yyyy   mm   dd  
G2   /   / 
  yyyy   mm   dd  
G1   /   / 
  yyyy   mm   dd  
Gender of additional drivers under 25 years of age:
Do driver(s) under 25 years of age have driver training certification?
Yes     No
Any at fault accidents in past 6 years?*
Yes     No
If Yes:  
Date of Accident:
 /   / 
yyyy   mm   dd  
Description:
   
Any driving convictions in past 3 years?*
Yes     No
Do you use your vehicle for business?*
Yes     No
Do you use your vehicle to commute to and from work?
Yes     No
Year, make and model
of vehicle*:
Coverage & Deductibles*:  
 
Liability:    
Collision:  
Comprehensive:  
Additional vehicles to be quoted?
Yes     No
If Yes:  
Age of principal driver:
Marital status of principal driver:
Enter years licensed:
 
G   /   / 
  yyyy   mm   dd  
G2   /   / 
  yyyy   mm   dd  
G1  /   / 
  yyyy   mm   dd  
Gender of additional drivers under 25 years of age:
Do driver(s) under 25 years of age have driver training certification?
Yes     No
Any at fault accidents in past 6 years?
Yes     No
If Yes:  
Date of Accident:
 /   / 
yyyy   mm   dd  
Description:
   
Any driving convictions in past 3 years?
Yes     No
Do you use your vehicle for business?
Yes     No
Do you use your vehicle to commute to and from work?
Yes     No
Year, make and model of vehicle:
Coverage & Deductibles:  
 
Liability:    
Collision:  
Comprehensive:  
   
Disclaimer:
 


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