First Name (Required) Last Name (Required)
Your email (Required)
Address Line 1 (Required)
Address Line 2
City (Required) Province (Required) Postal Code (Required)
Area Code (Required) Phone (Required) Cell
Preferred type of contact EmailPhoneCellEither Best time(s) to reach you by phone MorningAfternoonEvening
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What type of auto insurance do you need? Car or TruckMotorcycleClassic Car Are you interested in any of these types of insurance? Mature DriverYoung DriverGood Driver DiscountSnow Tire DiscountPay-As-You-Go Payment Plan Are you a CAA member? YesNo
Date of Birth (Required)
Have you been involved in any accidents or made any claims in the last 6 years? YesNo Have you had any Highway Traffic Act convictions in the last 3 years? YesNo
Year of Vehicle (Required) Make of Vehicle (Required) Model of Vehicle (Required)
Average Km per year Do you commute to work? YesNo
Have you been involved in any accidents or made any claims in the last 5 years? YesNo Have you had any Highway Traffic Act convictions in the last 3 years? YesNo
Type of Classic Car? YesNo Do you have a recent appraisal? YesNo
Value of Vehicle (Required)
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Current Insurance Company and Policy Expiry Date
Insurance Company Policy Expiry Date
Comments
How did you hear about Whitley Newman Insurance? (Required) Existing ClientInternet SearchOnline AdFriendFlyer or BrochureLink from another siteAt a showEmail newsletterOther
By submitting this form, I agree that Whitley Newman Insurance will use this information to contact me regarding insurance.
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