Automobile Insurance

Application for Automobile Insurance

(Owner's Form S.A.F. 1)

1. Applicant's full name and postal address (Including country or district):

Each described automobile is and will be chiefly used in the vicinity of the applicant's address above unless otherwise stated in the Remarks section overleaf.

2. Policy Period:
From
To

**All times are local times at the applicant's postal address stated herein.

3. Particulars of the Described Automobile(s):

Click the "add" button below to add information for a second, third, etc. vehicle.

4. Limits

Click the "add" button below to add limits for vehicle 2, vehicle 3, vehicle etc.

5. List all Drivers of the Described Automobile(s) in the Household or Business

Click the "add" button below to add information for a second, third, etc. driver.

6. Health Questions

If yes, state particulars in Remarks section at the bottom of the form.
If yes, state particulars in Remarks section at the bottom of the form.

7. a) Give particulars of all CONVICTIONS arising from the operation of any automobile during the past three years:

Click the "add" button below to add information for conviction 2, conviction 3, conviction etc.

7. b) Give particulars of all ACCIDENTS and CLAIMS arising from the ownership or operation of any automobile during the past SIX years.

Click the "add" button below to add information for accident 2, accident 3, accident etc.
If yes, state particulars in Remarks section at the bottom of the form.

9. a) Has any Insurer, to the knowledge of the applicant, cancelled, declined or refused to renew or issue automobile insurance to the applicant or drivers shown in item 5 within the THREE years proceeding this application? If so, state name of Insurer and policy number if available:

9. b) Details of Applicant's most recent automobile insurance:

10. Complete the following information for each vehicle. Add more fields by clicking the "Add" button below.

Click the "add" button below to add information for vehicle 2, vehicle 3, vehicle etc.

11. a) Will the automobile be rented or leased, or used for carrying passengers for compensation or hire, or for carrying explosives or radioactive material? If so, provide details for each vehicle listed in Section 5.

Click the "add" button below to add details for vehicle 2, vehicle 3, vehicle etc.

11. b) Will the automobile be used for the transportation of goods for compensation? If so, state class of license or certificate and radius of operations. Please provide details for each vehicle listed in Section 5.

Click the "add" button below to add details for vehicle 2, vehicle 3, vehicle etc.

Where (a) an Applicant for a contract, (i) gives false particulars of the described automobile to be insured to the prejudice of the Insurer, or (ii) knowingly misrepresents of fails to disclose in the application any fact required to be stated therein; or (b) the Insured contravenes a term of the contract of commits a fraud; or (c) the Insured willfully makes a false statement in respect of a claim under the contract, a claim by the Insured is invalid and the right of the Insured to recover indemnity is forfeited.

The applicant acknowledges that all of the information given by the applicant in items 1 through 13 and any particulars in Remarks section relating thereto are true and the applicant hereby applies for a contract of automobile insurance to be based on the truth of the said information.

The personal information collected on this application is needed to issue the policy. We are required to provide this information to the Underwriting Information Tracking System, which is a data bank operated on behalf of the automobile insurance industry for the purpose of statistical analysis, identification of eligible risks and the proper rating of those risks. The information in the data bank is available to all Insurance companies and insurance agents providing automobile insurance in Canada.

CONSENT: I am applying for automobile insurance based on the information provided in this application. I authorize you to collect, use and disclose the information on this form and any additional information about my driving record, automobile insurance policy and claims history and that of the listed drivers from whom I declare I have obtained consent for these purposes. I understand that this personal information is necessary to assess the risk, issue the insurance contract, renewal or change, detect and prevent fraud and investigate and settle any claims. If I apply for a premium payment plan, I authorize you to obtain and use my credit report.

Date: