Kami Insurance Agencies Ltd

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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