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AutoPlus & MVR Quote Request Form
For all Autoplus and/or MVR requests, please complete the form below.
Company
*
Aviva
Chieftain (24hr MVR)
Dominion/Travellers (24hr MVR)
Economical
Gore (24hr MVR)
Intact Personal Lines
Intact Commercial Lines
Jevco
Pafco
Perth (24hr MVR)
RSA Facility (24hr MVR)
Unica
Wawanesa
Producer
*
Alfaro, Lesley
Argier, Cathy
Da Eira, Rosa
Da Rosa, Simon
Desjardins, Rylan
Dominy, David
Dominy, Heather
Findlay, John
Fraser, Darryl
Fraser, Jonathan
Fraser, Scott
Gailitis, Carolyn
Ham, Alex
Ham, Sam
Kang, Jenny
Lai, Wendy
Lam, Julian
Mitton, Stephen
Moote, Brian
Oliveira, Jorge
Paul, Nadine
Persaud, David
Pirzas, Anastasia
Pirzas, Jim
Pirzas, John
Rnjak, Rosa
Rnjak, Zoran
Rnjak, John
Slichter, Kerrie
Sostegno, Gina
Sostegno, Pietro
White, Karen
Wilkinson, Karen
Wingfield, Andrea
Wingfield, Drewry
Wingfield, Roger
MKT
Department
*
Personal Lines
Commercial Lines
Sanctuary Plus
Client Code
*
Insured's Name
*
First
Last
Company Name
Church / Ministry Name
Reason for Request
*
New Policy
Addition of Driver
Company Request
Other
Bound Effective Date
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
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11
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14
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16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
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1987
1986
1985
1984
1983
1982
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Quote # or Policy #
*
Driver 1
Driver's Name
*
First
Last
Driver's License #
*
# of Convictions Disclosed
*
Unknown
0
1
2
3
4
5
More than 5
Records Requested: Driver 1
*
AutoPlus ONLY
MVR ONLY
BOTH AutoPlus & MVR
Check box to add additional drivers as needed
Driver 2
Driver 2
Driver's Name
*
First
Last
Driver's License #
*
# of Convictions Disclosed
*
Unknown
0
1
2
3
4
5
More than 5
Records Requested: Driver 2
*
AutoPlus ONLY
MVR ONLY
BOTH AutoPlus & MVR
Check box to add additional drivers as needed
Driver 3
Driver 3
Driver's Name
*
First
Last
Driver's License #
*
# of Convictions Disclosed
*
Unknown
0
1
2
3
4
5
More than 5
Records Requested: Driver 3
*
AutoPlus ONLY
MVR ONLY
BOTH AutoPlus & MVR
Check box to add additional drivers as needed
Driver 4
Driver 4
Driver's Name
*
First
Last
Driver's License #
*
# of Convictions Disclosed
*
Unknown
0
1
2
3
4
5
More than 5
Records Requested: Driver 4
*
AutoPlus ONLY
MVR ONLY
BOTH AutoPlus & MVR
Comments
Requested By
*
Your Email Address
