AXION-WALKER INSURANCE SERVICES

Name

Address

City

Province

Postal code

Phone number

Email address

Date of birth (DD/MM/YY)

Year, make, and model of vehicle

Do you use the vehicle to commute to work or school

Yes No

Years licensed in Canada

How many years of continuous auto insurance

Number of convictions in the last 3 years

Any suspensions in the last 3 years

Yes No

Number of claims of any kind in the last 10 years

Number of at-fault claims in the last 10 years

Any cancellations by any insurer in last 5 years

Yes No

Name of current insurer

Policy expiry date (DD/MM/YY)