Quotation Forms

Automobile Insurance Quote Form

Please be as precise as possible when filling out this form so that we may provide you with an accurate quotation.

First Name :
Last Name :

Street Address :
Town : Nova Scotia Postal Code :

E-Mail Address :
Fax Number :
Contact Telephone Number:

Please Indicate Your Preferred Method for Receiving
Your Automobile Comparison Quotation :
E-Mail
Fax
Letter
Telephone

Are You An Existing Client of C.C. Cleveland Insurance ?
Yes
No

Have You Had Insurance Coverage Cancelled by
an Insurance Company in the past 3 Years?

Yes
No
If YES, please provide date & details for cancellation(s):

How Many Vehicles Are In The Household?

Vehicle Information	Vehicle 1	Vehicle 2	Vehicle 3
Year & Make : ex. 2003 Pontiac
Model : ex.Grand AM SE
Select Body Type :
VIN (if available)
Use for Vehicle :

(If More Than 3 Vehicles, Please List In 'Additional Information' Text Box At Bottom)

Coverages	Vehicle 1	Vehicle 2	Vehicle 3
Liability :
Collision :
Comprehensive :
Sef 20-Loss of Use :
Sef 27- Legal Liability for Non-owned vehicles
SEF 13C - Deletion of Glass coverage

Drivers	Driver 1	Driver 2	Driver 3	Driver 4
Name
Date of Birth
License # :
Years Licensed
Years Insured
Driver Training

Has Any Drivers Had Any Convictions Within Past 3 Years ?
Yes
No
If Yes, Please Specify Driver, Dates & Type of Conviction :

Has Any Listed Driver Had Any Accidents Within Past 6 Years?
Yes
No
If Yes, Please Specify Driver, Dates & Brief Description :

Any Additional Information :

I have provided personal information with this submission & I may in the future provide future provide further personal information. Some of this personal information may include, but is not limited to, my credit information & claims history. I authorize C.C Cleveland Insurance Ltd to collect, use & disclose any of this personal information, subject to the law & to C.C.Cleveland Insurance's policy regarding personal information, for the purposes of communicating with me, assessing my submission for an insurance quote and underwriting my policy, evaluating claims, detecting & preventing fraud, & analyzing business results. I confirm that all individuals whose personal information is so provided have authorized that I agree to the above on their behalf.

Thank you for visiting C.C. Cleveland Insurance.

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