If you are interested in having Clarke-Slighte Insurance provide you with a quote please provide the information requested below. By filling out the form you will help us to serve you better and faster.

Note: Automobile insurance is only available for Ontario residents.
Note: all areas with * are required fields

All information will be kept strictly confidential and only used for the purpose of providing a quote.

Personal Details
*First Name *Last Name
*Day Phone Evening Phone
*Address
*City
Province Ontario
*Postal Code
E-mail Address

Vehicle Details (First Vehicle)
Make (eg. Ford) Model (eg. Mustang)
Body Type Year
Vehicle Leased? Yes No Any Modifications? Yes No
(If yes please list in the Additional information section)

Vehicle Details (Second Vehicle)
Make (eg. Ford) Model (eg. Mustang)
Body Type Year
Vehicle Leased? Yes No Any Modifications? Yes No
(If yes please list in the Additional information section)

Vehicle Use
Vehicle 1 Vehicle 2
Type of use
How far (in km, one way) do you drive to get to work?
What is your annual mileage (in km)?
How many full consecutive years have you been insured?
Are you currently insured?
If YES, how long?

Driver Information
Please list all drivers in your household/business.
Driver
No.		 Name Age Vehicle Sex Yrs. Licensed   Driver
Training
1 M F G1 G2 G Yes No
2 M F G1 G2 G Yes No
3 M F G1 G2 G Yes No
4 M F G1 G2 G Yes No
List details of all accidents or claims withing the last six years, whether at-fault or not at-fault, date of occurrence, and driver's name.


Prior Insurance Lapse of Insurance due to non payment At Fault Accident Date No.of Convictions in 3 yrs
Yes No Yes No Minor Date
Years Insured   Not At Fault Accident Date Major Date
  Serious Date

Coverage Required
Vehicle 1 Vehicle 2
Liability
Accident Benefits:
(weekly limit)
Collision Deductible
Comprehensive Deductible
If you prefer an all perils deductible in place of seperate collision and comprehensive deductibles, please select the checkbox beside "All Perils Deductible".
All Perils Deductible
Family Protection Yes No Yes No
Rental Car Yes No Yes No

Additional Information
Please enter any additional information that you think may assist us in providing you with a faster and more accurate quote.

How did you hear about us?
(eg. yellow pages, referral, search engine, etc.)

  Thank you for filling out the form!