Rai Grant Insurance Brokers

140 Renfrew Drive, Suite 230
Markham, ON L3R 6B3
1-905-475-5800 1-800-561-6195

Rai Grant Insurance Brokers
Automobile
Auto
Group Auto & Home Insurance

Property
Condominium
Home Owners
Tenant

Commercial auto
Fleets
Taxi's
Garage
Other Commercial Autos
Commercial
Boiler & Machinery
Bonds & Surety Bonds
Business Interruption
Commercial Liability
Commercial Property
Construction
Contractors
Import / Export
Manufacturers
Offices
Real Estate & Property Mg.
Retailers & Wholesalers
Life and Financial Insurance

Personal Insurance Solutions FORM

COMMENTS


Please take a moment to tell us how you heard about us:

Please tell us who refered you:
*(If it was a friend please write their full name in the space below)
CONTACT INFORMATION
First Name* Last Name*
Address* Phone*
City* Phone 2
Province* E-Mail*
Postal Code* Contact Method Phone Email
INSURANCE INFORMATION
How many years have you been insured in Canada / US without interruption?*
Has your insurance been cancelled in the past 3 years for non payment?* Yes No
With what company are you currently insured?
What is your current auto policy number?
What is the expiry date of your current policy?
What is your current annual premium? $
Why are you looking for a new insurer or broker?
VEHICLE INFORMATION (Please call for a quote on more than 4 vehicles)
Information Vehicle 1 Vehicle 2
Year*
Make*
Model*
Style*
Anti Theft Protection Yes No Yes No
Airbags Yes No Yes No
Is the vehicle driven to work?* Yes No Yes No
If yes, how far one way? (km)
Vehicle Use*
Annual kilometers*
DRIVER INFORMATION (Please call for a quote on more than 4 drivers)
Information Driver 1 Driver 2 Driver 3
Name*
Gender* M F MF MF
Date of Birth*
License Class*
First Lisensed in Canada*
Principal Driver* Yes No Yes No Yes No
Vehicle Mainly Driven
Driver Training Yes No Yes No Yes No
MANDATORY COVERAGES
Coverage Vehicle 1 Vehicle 2
Third Party Liability
Accident Benefits (see below for optional increase) standard standard
Uninsured Automobile Coverage included included
Direct Compensation Property Damage - Deductible
OPTIONAL COVERAGES (Select from any of the desired coverages below)
Coverage Vehicle 1 Vehicle 2
Collision (choose deductible)
Comprehensive (choose deductible)
OPCF 19a - Agreed Value of Automobiles
OPCF 20 - Loss of Use
OPCF 27 - Rental Liability
OPCF 38 - Electronic Accessories & Equipment ($1500 included in standard policy)
OPCF 43/43a - Waiver of Depreciation
INCREASED ACCIDENT BENEFITS (Standard benefits are already INCLUDED in your mandatory coverage)
Coverage Vehicle 1 Vehicle 2
Income Replacement
Income Replacement Indexation
Increased Limit for Medical, Rehabilitation & Attendant Care
Increased Death Benefit
Increased Caregiver and Dependant Care Coverage
CLAIMS (Please list all claims in past 6 years. Include non accident claims, ie. theft)
Driver name Date of Claim Claim Payout ($) Details of Claim
CONVICTIONS (Please list all tickets, excluding parking tickets)
Driver name Date of Ticket Details of Ticket
THANK YOU!



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