Autoplan Quick Quote Form

(For residents of British Columbia only)

All estimates confidential, and for our company use only: no access given to outside mailing lists or agencies.

Name:
Address:
City:
Province:
Postal Code:
Phone #:
Fax #:
E-mail address:	(essential)

General

What is the postal code of the place where the vehicle is parked at night?

Do you drive the vehicle for:

Pleasure only:
Pleasure & to work or school less than 15 km one way distance:
Pleasure & to work or school more than 15 km one way distance:
Business use:
Delivery: Specify:
Artisan:
Other:Specify:

Will you or any member of your household be driving your vehicle who has less than ten years driving experience?
Will the registered owner and the principal operator of the vehicle be age 65 or over?
How much liability coverage do you want:
Do you want collision coverage?
Do you want comprehensive coverage?
Do you want the Roadstar or Roadside Plus packages?
If your vehicle is less than five years old would you like replacement cost coverage or limited depreciation coverage?
Do you want loss of use coverage?
How long do you wish to insure your vehicle?
Do you want to pay your premiums monthly by Autoplan 12?
If yes, is this the first time you have used Autoplan 12 for this licence plate? (If yes, you will need to supply a voided personalized cheque.)
What is the make of the vehicle?:
What is the model of the vehicle?:
What is the year of the vehicle?:
What is the net weight of the vehicle?:
Do you want a new licence plate?:
Do you need to have the vehicle registered in your name?:
What is your B.C. Driver's license number?:
If you are from out of province how many years of claim free driving can you prove you have by obtaining letters from your previous insurers?:

What is your discount or surcharge? Percentage:

Do you have a passive electronic imobilizer anti-theft device installed in your vehicle?

If you have any questions or comments, please enter here: