Policy Review | One Stop Licence Shop

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First and Last Name

Email Address

Phone number

Have you bought a new vehicle that is not listed on your auto insurance policy?

Yes (Please Explain)

YES (please explain)

Have you sold a vehicle that is still listed on your auto insurance policy?

Yes (please explain)

YES (explain)

Have you modified your vehicle (ex: stereo system/made handicap accessible/paint/graphics)?

Yes (please explain)

YES (please explain)

YES (how many kilometers do you commute one way)

Please provide the number of kilometers you drive annually:

Have you started driving for Uber or other ridesharing service, or do you independently drive passengers for compensation?

Yes (please explain)

YES (please explain)

Have you purchased any motorcycles, ATVs, mini-bikes, mopeds, motorized scooters, campers, motorhomes, golf carts or trailers?

Yes

Yes Please Explain

Do you have a new licensed driver in your household that needs to be added to your auto policy?

Yes

YES, please Explain

Have you had any traffic violations or tickets in the last 3 years? If so, please provide the details.

Yes

Yes, Please Explain

Are you thinking about increasing any of your deductibles to lower your premiums?

Yes

Yes, Please Explain

Would you like to move your home insurance to the same company for a discount?

Yes

If yes, please provide the expiry date of your home insurance

For an additional discount of up to 25% would you consider using a device in your vehicle that scores your driving performance?

Yes

If yes, please provide the details

How do you prefer that we contact you?

Phone

Do you give us permission to share your insurance information with another insurance brokerage for the purpose of obtaining other insurance options for you?

YES (please check below)

By clicking on the box below (AGREE), I authorize One Stop Insurance Inc. to release my insurance personal information to another brokerage that can offer a wider selection of insurance options to me and for the purpose of assisting me in obtaining insurance coverage

YES I AGREE

NO, I DISAGREE

I acknowledge that Intact Insurance will NOT be renewing my insurance policy. Completion of this authorization and questionnaire does not change the fact that my vehicle and/or home will be uninsured unless I take steps to reinsure it by completing a new insurance application. Coverage cannot be bound by completing this form. I acknowledge that I must receive written confirmation from a broker confirming new coverage.

YES, I AGREE

Do you have any other insurance questions or concerns?

POLICY REVIEW FORM