Mitchell Sandham
 
Overview
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Choose an Office:
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Drivers Licence number:
Have you ever been cancelled for non-payment, non-disclosure or misrepresentation?
Yes     No
Do you currently insure your car?
Yes     No
If not, have you had insurance for 12 consecutive months within the last 6 years?
Yes     No
When should coverage start? (dd/mm/yyyy)
Do you presently have home insurance?
Yes     No
Driver(s) Information:
#1 #2 #3
Name:
Age:
Years licensed in Canada:
License class:
Sex:
Marital status:
Driving school:
Retired?
Minor traffic convictions in the last 3 yrs:
Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.):
Are you currently insured?
Yes     No
Name of previous insurance company:
Have any of above drivers had their licenses suspended or lapsed in the past 6 years?
Yes     No
Have any of the drivers above had accidents or claims in the past 10 years?
Yes     No
Claims Information:
Claims Date (mm/yyyy) Driver involved
#1:
#2:
#3:
   
Vehicle Information:
Vehicle #1 Vehicle #2
Vehicle make:
Year:
Model:
Style:
Use:
KM driven one way to work:
Kilometres driven per year:
Who is primary driver:
   
Coverage Required:
Vehicle #1 Vehicle #2
Liability:
Collision deductible:
Comprehensive deductible:
 

Disclaimer
 
Mitchell Sandham Inc.
Toronto, ON >> click here
Mitchell Sandham Pastor
Mississauga, ON >> click here
Mitchell Sandham Financial Services
Toronto, ON >> click here
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