Touchstone Insurance

Here for you today & tomorrow.

Who We Are Report A Claim Contact Partners/Friends


Automobile

Please complete the following form in as much detail as possible in order for us to ensure the best pricing possible. We may ask for a little more information depending on your answers. One of our expert advisors will be in touch within 24 business hours.

Form Navigation:

Top
Personal Information
Insurance Information
Driver Information
Claim Information
Vehicle Information
Coverage Information
Other Information
Comments
Consent

Fields marked with ( * ) are required.
Links to more details are marked with an underline.
Personal Information *First name:
*Last name:
*Address:
*City:
*Postal Code:
*Main Phone:
Ext.
*E-Mail:
How did you hear about us?
Referral I am a current client Media Ad Beyond.ca Yellowpages.ca Google Other
Please let us know who referred you so we can thank them:
Please provide some additional details:
Insurance Information Do you currently hold insurance elsewhere in Canada? Yes No
Province held in:
Insurance Company (not broker):
Policy Number (if possible):
Expiry date of current or last policy:
How many years have you been continuously insured?
Has ANY insurance company cancelled any of your policies for any reason in the past 5 years? Yes No
If yes, please explain:
Do you currently hold property insurance of any kind? Yes No
Driver Information
Driver 1 Driver 2 Driver 3
Name:
*Date of Birth:
Sex:
Marital Status:
Years licensed in Canada: years years years
License Class:
Driver training in past 3 yrs?: Yes No Yes No Yes No
Occupation (possible discounts):
Traffic convictions of ANY KIND in the past 3 years?
Yes No Yes No Yes No
If yes, list offence and approximate date of conviction:
License suspended AT ALL in the past 6 years?
Yes No Yes No Yes No
If yes, list effective dates and reason for the suspension:
Claims of ANY KIND in past 6 years?
Yes No Yes No Yes No
If yes, please complete Claim Information.
Claim Information
Type of Claim Date of Claim Driver Involved
1.
2.
3.
Vehicle Information
Vehicle 1 Vehicle 2 Vehicle 3
Year:
Make:
Model:
Style:
Use:
Coverage Information
Vehicle 1 Vehicle 2 Vehicle 3
Third Party Liability:
Collision:
Comprehensive:
Other Information Are there any other licensed operators in the household who are not listed here? Yes No
If yes, please explain why they are excluded:
Are there any other vehicles attached to your residence which are not listed here? Yes No
If yes, please explain why they are excluded:
Comments


Thank you for taking the time to fill out this form. Select the "Submit" button below and we will contact you by the next business day. Our quote will include the coverages you selected. We may include the cost of popular optional coverages with our quotation.

We are sorry, but we are unable to provide you with a quote at this time. Please contact us if you have any other inquiries.

I changed my mind, show me the form again (Don't worry your response hasn't been deleted)