Full Name

Address

Full Address

Driving Distance Declaration

1 2 3 4 5

Winter Tire Declaration

Applied winter tire discount
On making application for a Winter Tire Discount, I declare that: Four (4) winter tires are installed on the vehicle(s) described above during the months from Nov 1st through to April 31st.
I declare that the information above is correct and in the event that I knowingly misrepresented or failed to disclose any facts related to my insurance policy it may be cancelled for misrepresentation or any claim may be denied.

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UNDERWRITING DECLARATION

Business Exposure?
Purchase Optional AB
Signed PAC Form and Void check on file
Address Match on driver's license, MVR, Ownership
Does spouse have driving license ?
All previous drivers remain unchanged
Out of country/ fast track/ exchange license drivers:
Insurance lapses Write reason
Detail explanation on 0 KM commute distance/ office address for 5 KM or less commute distance
Annual Kms less than or equal to 8000 kms
Require Underwriter’s Approval
Combined Policy/Multi-line discount
Group Discount
Vehicle use for Uber/Food Delivery/Ride Sharing
DTC discount added

AUTO COVERAGE DECLARATION

Liability Coverage
Collision Coverage
Comprehensive Coverage
OPCF 43 – Waiver of Depreciation:
Accident Protector Coverage:
Conviction Protection
OPCF 20 – Loss of Use Coverage:

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Telematics / App

I understand the details of Telematics/User-Based Insurance and agree to enroll. I will download and keep the telematics app installed and actively use it as required. I acknowledge that my discount is conditional on continuous participation and may be removed if I do not comply. Considering these terms, I confirm my consent to enroll in the Telematics discount program.
No of Telematics
0 1 2 3 4 5
Additional Notes Full Name


Insured Signature




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