Underwriting For Auto Insurance
Spoke to Broker
Effective Date
Basic Information
Full Name
MVR Completed on
Autoplus/Dash Completed on
Address
Full Address
Driving Distance Declaration
0
1
2
3
4
Winter Tire Declaration
Applied winter tire discount
Yes
No
Insured noted winter tire must be installed during Nov to April
Yes
Not Applicable
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.
Yes, Agreed
Not Applicable
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.
Yes, Agreed
Not Applicable
AUTO DECLINE COVERAGE DECLARATION
Business Exposure?
Yes
Declined
Purchase Optional AB
Yes
Declined
Signed PAC Form and Void check on file
Yes
No
Not Applicable
Address Match on Drives license, MVR, Ownership
Yes
No
Does spouse have driving license ?
Yes Added
Yes Not Added
No
All previous drivers remain unchanged
Yes
No
Out of country/ fast track/ exchange license drivers:
Yes
No
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
Yes
No
Require Underwriter’s Approval
Yes
No
Liability Coverage
1 Million
2 Million
Collision Coverage
Yes
Declined
Comprehensive Coverage
Yes
Declined
OPCF 43 – Waiver of Depreciation:
Yes
Not Applicable
Declined
Accident Protector Coverage:
Yes
Not Applicable
Declined
Conviction Protection
Yes
Not Applicable
Declined
OPCF 20 – Loss of Use Coverage:
Yes
Declined
Combined Policy/Multi-line discount
Yes
No
Group Discount
Yes
No
Telematics / App
0
1
2
3
4
5
Vehicle use for Uber/Food Delivery/Ride Sharing
Yes
No
DTC discount added
Yes document collected
No
Additional Notes
Generate
Copy
Scroll to Top
