W C Porter Insurance - Woodstock, NB
W C Porter Insurance - Woodstock, NB

     Welcome to our convenient Automobile Insurance Quotation Request form.  We request that you have the following information available in order to complete your request: The year, make and model of your vehicle; Driving records; License information: Claim information for each driver of the vehicle.
     Incomplete or partial form requests will make it difficult or impossible for us to fulfill your quotation request. Please be sure you accurately and fully complete the entire form to ensure a speedy response from one of our representatives.


Section 1  - Contact Information

Your full name :

Street address :

Town / City :

Province :

 Postal Code :

Contact telephone number :

E-Mail Address :

What time of day would
you like to be contacted? :

Section 2  - Basic Information

How many vehicles would be on this policy? :

How many drivers would be on this policy?  :

When does your current automobile 
insurance policy expire? :

   

Section 3  - Vehicle Information (First Vehicle)

Make of 1st vehicle? :

Model of 1st vehicle? :

Year of 1st vehicle? :

Primary use of 1st vehicle? :

Amount of Public Liability Coverage
requested on 1st vehicle?:

All Perils Deductible on 1st vehicle?:

Collision Deductible on 1st vehicle?:

Comprehensive Deductible on 1st vehicle?:

Specified Perils Deductible on 1st vehicle?:

If commuting, what are the the number
of KM driven daily with 1st vehicle (one way)?:

Approximate KM driven annually?  (1st vehicle) :

Section 4  - Vehicle Information (Second Vehicle)
(Where applicable)

Make of 2nd vehicle? :

Model of 2nd vehicle? :

Year of 2nd vehicle? :

Primary use of 2nd vehicle? :

Amount of Public Liability Coverage
requested on 2nd vehicle?:

All Perils Deductible on 2nd vehicle?:

Collision Deductible on 2nd vehicle?:

Comprehensive Deductible on 2nd vehicle?:

Specified Perils Deductible on 2nd vehicle?:

If commuting, what are the the number
of KM driven daily with 2nd vehicle (one way)?:

Approximate KM driven annually? (2nd vehicle) :

Section 5  - Driver Information (Driver 1)

Complete name? :

Date of birth? :

Gender? :

Marital Status? :

Class of driverís license? (5, 5a, etc.) :

Date driverís license was obtained? :

Do you possess a driverís training certificate? :

How many years have you had continuous insurance coverage in North America? :

Have you had insurance coverage cancelled by an insurance company in the last 3 years? :

Have you had your driverís license suspended in the last 6 years? :

How many traffic tickets have you had in the last 3 years? (Not parking tickets) :

How many claims, not involving accidents, have you had in the past 3 years? :

How many accidents have you
had in the past 6 years? :

Section 6  - Driver Information (Driver 2)
(Where applicable)

Complete name? :

Date of birth? :

Gender? :

Marital Status? :

Class of driverís license? (5, 5a, etc.) :

Date driverís license was obtained? :

Do you possess a driverís training certificate? :

How many years have you had continuous insurance coverage in North America? :

Have you had insurance coverage cancelled by an insurance company in the last 3 years? :

Have you had your driverís license suspended in the last 6 years? :

How many traffic tickets have you had in the last 3 years? (Not parking tickets) :

How many claims, not involving accidents, have you had in the past 3 years? :

How many accidents have you
had in the past 6 years? :

Section 7  - Driver Information (Driver 3)
(Where applicable)

Complete name? :

Date of birth? :

Gender? :

Marital Status? :

Class of driverís license? (5, 5a, etc.) :

Date driverís license was obtained? :

Do you possess a driverís training certificate? :

How many years have you had continuous insurance coverage in North America? :

Have you had insurance coverage cancelled by an insurance company in the last 3 years? :

Have you had your driverís license suspended in the last 6 years? :

How many traffic tickets have you had in the last 3 years? (Not parking tickets) :

How many claims, not involving accidents, have you had in the past 3 years? :

How many accidents have you
had in the past 6 years? :

Section 8  - Submit Your Request

Any Additional Comments
or Required Coverages? :

Terms of Use:   By checking off the ďYESĒ box to the left you are stating that all information which you have provided on this on-line request is true, accurate, current and complete. Agreement with the ďTerms of UseĒ also deems that W. C. Porter Insuance may use the information you have provided as outlined in our ďPrivacy StatementĒ. You are also stating that you acknowledge and accept the terms and conditions of the Privacy Statement, as provided by W.C. Porter Insurance.

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