Get a Quote for your Auto Insurance – Alberta Insurance Corp

PRIMARY DRIVER/APPLICANT*

First Name

Last Name

Primary Driver: Phone Number*

Primary Driver Email*

Primary Driver - Date of Birth*

day

/

month

/

year

Your Gender*

Male

Female

Marital Status*

Married

Not Married

ADDRESS*

Street Address City State / Province / Region Postal / Zip Code

Do you own or rent your home?*

Your Occupation*

Did you complete a driver education course?*

When does your current policy expire?*

# of years of continuous insurance in Canada*

Primary Driver: Driver's Licence number*

Primary Driver: # of tickets (within last 3 years) after being pulled over?*

Primary Driver: # of claims at-fault within the last 6 years*

Second Driver ( if applicable )

First Name

Last Name

Second Driver: Phone Number

Second Driver - Date of Birth

day

/

month

/

year

Second Driver: Gender

Male

Female

Does the Second Driver have his/her own auto insurance policy?

Yes

No

Second Driver: Occupation

Second Driver: Driver's Licence number

# of years of continuous insurance in Canada

Second Driver: # of claims at-fault within the last 6 years

Second Driver: # of tickets (within last 3 years) after being pulled over?

Primary Car Information*

Enter your answers:

- Make

- Model

- Year

- Number of km commuting to work ( one way )

Primary Car: VIN number ( type the number or n/a )*

Do you need Full Coverage or Liability only?*

Full Coverage

Liability only

Is your car #1 paid off ?*

Yes

No

Second Car Information ( if applicable )

Enter your answers:

- Make

- Model

- Year

- Number of km commuting to work ( one way )

Second Car: VIN number ( type the number or n/a )

Do you need Full Coverage or Liability only? (2nd car)

Full Coverage

Liability only

Is your car # 2 paid off ?

Yes

No

Additional Information ( (e.g more cars or drivers - please provide all details as above)