Online Auto QUOTE Request

 

Simply fill out the appropriate fields below, click submit, and a Miller Insurance Broker will be happy to provide you with a quote.

 

PERSONAL INFORMATION

 

First Name                 Home Phone # 

Last Name                  Work Phone # 

Address                     E-mail address:

City             

Province     

Postal Code

 

How do you prefer to be contacted?  

 

Do you presently have any type of insurance with Miller Insurance Brokers?

 

Are you employed by Bruce Power or South Bruce Grey Health Centre?

 

 

VEHICLE INFORMATION

 

Vehicle #1       Year                     Make & Model                                                  Type

                                                              

 

 

Do you commute to work?             If yes, how far one way?               

Approximate mileage per year (km)?                       

 

Current coverage (or desired coverage)

Liability                                                     

Collision    (if yes, please select deductible) 

Comprehensive   (if yes, please select deductible)       

Loss of Use Coverage 

Accident Waiver / RDG 

Other

 

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Vehicle #2       Year                     Make & Model                                                  Type

                                                              

 

 

Do you commute to work?                If yes, how far one way?             

Approximate mileage per year (km)?                         

 

Current coverage (or desired coverage)

Liability                                                     

Collision    (if yes, please select deductible) 

Comprehensive   (if yes, please select deductible)       

Loss of Use Coverage 

Accident Waiver / RDG 

Other

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Vehicle #3       Year                     Make & Model                                                  Type

                                                              

 

 

Do you commute to work?                   If yes, how far one way?                

Approximate mileage per year (km)?                         

 

Current coverage (or desired coverage)

Liability                                                     

Collision    (if yes, please select deductible) 

Comprehensive   (if yes, please select deductible)       

Loss of Use Coverage 

Accident Waiver / RDG 

Other

 

  DRIVER INFORMATION

( Please list all the drivers in your household to be insured by this policy)

 

 

   #1 Driver

 

  Full Name   Birth Date

  Sex                       Martial Status

  Lic. Class            Date Issued

  Insured Since                        Driver Training

 

  

    #2 Driver

 

  Full Name   Birth Date

  Sex                      Martial Status

  Lic. Class           Date Issued

  Insured Since                      Driver Training

 

  

    #3 Driver

 

  Full Name Birth Date

  Sex                     Martial Status

  Lic. Class          Date Issued

  Insured Since                      Driver Training

 

 

Please note, for any drivers licensed less than 6 years, G1, G2 and G license dates will be required.

 

 

 

DRIVING RECORD / AUTO INSURANCE QUESTIONS

Have you or any driver in your household had any of the following?

Automobile claims in the past 10 years: 

 

If you’ve had a claim (s), please indicate when and a brief description of type:

 

 

 

 

Traffic convictions in the last 3 years: 

 

If you’ve had a conviction (s), please indicate when and a brief description of type:

 

 

  

License suspensions in the last 6 years?  

If yes, please provide details below:

 

 

 

Have you ever been cancelled for non-payment of premium? 

Are you currently insured? 

Have you ever had a lapse in insurance coverage? 

Are there any other drivers in the household not listed on the policy? 

 

 

I also need coverage for:

 

Property Insurance (Homeowners / Tenant’s / Condo)

Boat

Seasonal Dwelling or Trailer

Rental Property

Home Based Business

Jewellery

 

 Which office do you wish to deal with for your insurance needs?

 

 

 By checking this box, I indicate that I have read, understood and AGREE to the terms of Miller Insurance Brokers’ Privacy Statement.

 

DISCLAIMER: By submitting this request for quotation, it is hereby understood that this is not a Policy of Insurance, Insurance Application or Offer by Miller Insurance Brokers Inc. to insure on behalf of any company.  We reserve the right to accept or deny any and all request, upon examination and analysis.