To obtain an insurance quote from INTACT INSURANCE CO., please complete this form and email or fax (604-876-7909) to Kami Insurance at least two days before your current insurance expires.
Effective/Renewal Date of ICBC Policy:______
Insured / Driver
Name:______Gender: Male / Female
Mailing Address:______
Location Address of where the vehicle is parked at night: ______
(If different from mailing address)
Residence Phone:______Email:______
Date of Birth:______Date of License:______
Number of Years Fault Free:______Driver’s License Number:______
Marital Status: Single / Married
Hasanyinsurercancelled,declinedorrefusedto reneworissueautomobileinsurancetothe applicantordriverslisted(onthepolicy)within the3yearsprecedingthisapplicationorhas anyclaimbeendeniedformaterialmisrepresentation? YES / NO
Is any driver being charged the Driver Risk Premium / Driving Infractions?YES / NO
# of At-fault losses:# of minor MV infractions:
# of Not-at-fault losses:# of MAJOR MV infractions:
Additional Drivers
Name:______Gender: Male / Female
Date of Birth:______Date of License:______
Number of Years Fault Free:______Driver’s License Number:______
Marital Status: Single / Married
Occasional Male Operator Under 25 Years Of Age (answer only if applicable)
Will there be a Male operator, aged 25 of younger occasionally driving this vehicle? YES / NO
Date of Birth:______Date of License:______
Number of Years Fault Free:______
Is this vehicle currently insured by Intact?YES / NO
Vehicle Information
Make:______EXACT Model name: ______
Year:______VIN:______
Vehicle Use:______Declared Value:______
Annual Kms driven (estimate):______(kms)Commute Kms (annual est.): ______kms
Coverages
Third-Party Liability limit desired
□ $1,000,000□ $2,000,000□ $3,000,000□ $4,000,000□ $5,000,000
Collision Deductible (the higher the deductible, the lower the premium)
□ $200□ $300□ $500□ $1,000□ $2,500
Comprehensive Deductible(the higher the deductible, the lower the premium)
□ $200□ $300□ $500□ $1,000□ $2,500
Endorsements
Excess Underinsured Motorist Protection (to protect you from other drivers who don’t carry adequate coverage, if you or your passengers are injured)
□ $1 Million□ $2 Million□ $3 Million□ $4 Million
□ Glass – Windshield Exclusion Endorsement (this will reduce your premium)
□ Limited Waiver of Depreciation Endorsement
□ Replacement Cost Endorsement
□ Claims Advantage ($10) (no deductible on total losses + Hit & Run deductible waived)
□ Expert Driver Package ($20 / $60)
Discounts
□ Multi Vehicle Discount (10% discount if you add your other cars to Intact’s policy)
□ My Home & Auto DiscountHome Policy #:______Auto Policy #:______
□ Anti-Theft Discount (If your car has an Immobilizor, you save 5% off the Comprehensive premium)
Additional Notes
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