Policy Checkup: Auto

A checkup is as important for your insurance as it is for your personal health! This form will allow Capital Insurance Brokers to ensure accuracy of your insurance policy, double-check for discounts, and if necessary rework your upcoming renewal.

At any time, you can save your work in progress and come back by clicking the "Save and Continue Later" button near the bottom of the page. Once the form is complete, please make sure to click the "Submit" button to finalize the form for our brokers to review.

1 Contact Info

2 Drivers & Vehicles

3 Coverage & Discounts

Assigned Broker
Client name*
Policy number*
Email
Best primary contact number
Secondary contact number
Please verify current address
Street Address Address Line 2 City Province Postal Code

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Driver Details
List of drivers on policy:
Are there any other people in the household with a driver license that are not already listed above?*
- Yes
- No
Please note that all drivers living in the household must be disclosed, regardless of whether they have access to your vehicle or not.
Please provide the following Information for the unlisted drivers: name, date of birth, occupation, and what vehicle they are currently driving.*
How many vehicles are there on this policy?*
- 1
- 2
- 3
- 4
- 5
- 6
Vehicle 1
Please type in the year, make model of vehicle #1 on your policy:*
Veh 1: Would you like to make any changes to the existing coverages on the policy for this vehicle?*
- Yes, make changes
- No, keep all coverages the same
Veh 1: Please indicate any coverage changes you would like make to this vehicle (ex: increase liability limit, delete collision coverage, etc.).*
Please note that no changes will take effect until a broker has reviewed and called to finalize the change.
Veh 1: Who is the primary operator of this vehicle?*
Veh 1: If there are any occasional operators of this vehicle that are NOT listed as primary operators on another vehicle on this policy, list them here:
Veh 1: Does any driver of this vehicle have any traffic convictions (pull-over only) within the past 3 years, OR at-fault claims within the past 6 years?*
- Yes
- No
Veh 1: Please provide dates and details of those tickets within the past 3 years and claims within the past 6 years for the drivers of this vehicle (if you're unsure of date, just make your best guess):*
Veh 1: One-way commute: How many kms is the vehicle driven to go to work or school?*
Veh 1: Estimated total annual kms for this vehicle (average is between 15,000 to 25,000 for most working adults):*
Veh 1: Is there any business or commercial use for this vehicle whatsoever - such as driving for hire, carrying tools or materials for a trade, transporting goods or passengers for hire, etc.*
- Yes, some business or commercial use
- No business or commercial use whatsoever
Veh 1: Please provide details of the potential business/commercial use for this vehicle:*
Vehicle 2
Please type in the year, make model of vehicle #2 on your policy:*
Veh 2: Would you like to make any changes to the existing coverages on the policy for this vehicle?*
- Yes, make changes
- No, keep all coverages the same
Veh 2: Please indicate the coverage changes you would like to make to this vehicle (ex: increase liability limit, delete collision coverage, etc.):*
Please note that no changes will take effect until a broker has reviewed and called to finalize the change.
Veh 2: Who is the primary operator of this vehicle?*
Veh 2: If there are any occasional operators of this vehicle that are NOT listed as primary operators on another vehicle on this policy, list them here:
Veh 2: Does any driver of this vehicle have any traffic convictions (pull-over only) within the past 3 years, OR at-fault claims within the past 6 years?*
- Yes
- No
Veh 2: Please provide dates and details of those tickets within the past 3 years and claims within the past 6 years for the drivers of this vehicle (if you're unsure of date, just make your best guess):*
Veh 2: One-way commute: How many kms is the vehicle driven to go to work or school?*
Veh 2: Estimated total annual kms for this vehicle (average is between 15,000 to 25,000 for most working adults):*
Veh 2: Is there any business or commercial use for this vehicle whatsoever - such as driving for hire, carrying tools or materials for a trade, transporting goods or passengers for hire, etc.*
- Yes, some business or commercial use
- No business or commercial use whatsoever
Veh 2: Please provide details of the potential business/commercial use for this vehicle:*
Vehicle 3
Please type in the year, make model of vehicle #3 on your policy:*
Veh 3: Would you like to make any changes to the existing coverages on the policy for this vehicle?*
- Yes, make changes
- No, keep all coverages the same
Veh 3: Please indicate the coverage changes you would like to make to this vehicle (ex: increase liability limit, delete collision coverage, etc.):*
Please note that no changes will take effect until a broker has reviewed and called to finalize the change.
Veh 3: Who is the primary operator of this vehicle?*
Veh 3: If there are any occasional operators of this vehicle that are NOT listed as primary operators on another vehicle on this policy, list them here:
Veh 3: Does any driver of this vehicle have any traffic convictions (pull-over only) within the past 3 years, OR at-fault claims within the past 6 years?*
- Yes
- No
Veh 3: Please provide dates and details of those tickets within the past 3 years and claims within the past 6 years for the drivers of this vehicle (if you're unsure of date, just make your best guess):*
Veh 3: One-way commute: How many kms is the vehicle driven to go to work or school?*
Veh 3: Estimated total annual kms for this vehicle (average is between 15,000 to 25,000 for most working adults):*
Veh 3: Is there any business or commercial use for this vehicle whatsoever - such as driving for hire, carrying tools or materials for a trade, transporting goods or passengers for hire, etc.*
- Yes, some business or commercial use
- No business or commercial use whatsoever
Veh 3: Please provide details of the potential business/commercial use for this vehicle:*
Vehicle 4
Please type in the year, make model of vehicle #4 on your policy:*
Veh 4: Would you like to make any changes to the existing coverages on the policy for this vehicle?*
- Yes, make changes
- No, keep all coverages the same
Veh 4: Please indicate the coverage changes you would like to make to this vehicle (ex: increase liability limit, delete collision coverage, etc.):*
Please note that no changes will take effect until a broker has reviewed and called to finalize the change.
Veh 4: Who is the primary operator of this vehicle?*
Veh 4: If there are any occasional operators of this vehicle that are NOT listed as primary operators on another vehicle on this policy, list them here:
Veh 4: Does any driver of this vehicle have any traffic convictions (pull-over only) within the past 3 years, OR at-fault claims within the past 6 years?*
- Yes
- No
Veh 4: Please provide dates and details of those tickets within the past 3 years and claims within the past 6 years for the drivers of this vehicle (if you're unsure of date, just make your best guess):*
Veh 4: One-way commute: How many kms is the vehicle driven to go to work or school?*
Veh 4: Estimated total annual kms for this vehicle (average is between 15,000 to 25,000 for most working adults):*
Veh 4: Is there any business or commercial use for this vehicle whatsoever - such as driving for hire, carrying tools or materials for a trade, transporting goods or passengers for hire, etc.*
- Yes, some business or commercial use
- No business or commercial use whatsoever
Veh 4: Please provide details of the potential business/commercial use for this vehicle:*
Vehicle 5
Please type in the year, make model of vehicle #5 on your policy:*
Veh 5: Would you like to make any changes to the existing coverages on the policy for this vehicle?*
- Yes, make changes
- No, keep all coverages the same
Veh 5: Please indicate the coverage changes you would like to make to this vehicle (ex: increase liability limit, delete collision coverage, etc.):*
Please note that no changes will take effect until a broker has reviewed and called to finalize the change.
Veh 5: Who is the primary operator of this vehicle?*
Veh 5: If there are any occasional operators of this vehicle that are NOT listed as primary operators on another vehicle on this policy, list them here:
Veh 5: Does any driver of this vehicle have any traffic convictions (pull-over only) within the past 3 years, OR at-fault claims within the past 6 years?*
- Yes
- No
Veh 5: Please provide dates and details of those tickets within the past 3 years and claims within the past 6 years for the drivers of this vehicle (if you're unsure of date, just make your best guess):*
Veh 5: One-way commute: How many kms is the vehicle driven to go to work or school?*
Veh 5: Estimated total annual kms for this vehicle (average is between 15,000 to 25,000 for most working adults):*
Veh 5: Is there any business or commercial use for this vehicle whatsoever - such as driving for hire, carrying tools or materials for a trade, transporting goods or passengers for hire, etc.*
- Yes, some business or commercial use
- No business or commercial use whatsoever
Veh 5: Please provide details of the potential business/commercial use for this vehicle:*
Vehicle 6
Please type in the year, make model of vehicle #6 on your policy:*
Veh 6: Would you like to make any changes to the existing coverages on the policy for this vehicle?*
- Yes, make changes
- No, keep all coverages the same
Veh 6: Please indicate the coverage changes you would like to make to this vehicle (ex: increase liability limit, delete collision coverage, etc.):*
Please note that no changes will take effect until a broker has reviewed and called to finalize the change.
Veh 6: Who is the primary operator of this vehicle?*
Veh 6: If there are any occasional operators of this vehicle that are NOT listed as primary operators on another vehicle on this policy, list them here:
Veh 6: Does any driver of this vehicle have any traffic convictions (pull-over only) within the past 3 years, OR at-fault claims within the past 6 years?*
- Yes
- No
Veh 6: Please provide dates and details of those tickets within the past 3 years and claims within the past 6 years for the drivers of this vehicle (if you're unsure of date, just make your best guess):*
Veh 6: One-way commute: How many kms is the vehicle driven to go to work or school?*
Veh 6: Estimated total annual kms for this vehicle (average is between 15,000 to 25,000 for most working adults):*
Veh 6: Is there any business or commercial use for this vehicle whatsoever - such as driving for hire, carrying tools or materials for a trade, transporting goods or passengers for hire, etc.*
- Yes, some business or commercial use
- No business or commercial use whatsoever
Veh 6: Please provide details of the potential business/commercial use for this vehicle:*

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Combined discount and additional coverages
You're almost done! The questions in this section will allow us to fine tune your coverage and look for additional discounts that you may be eligible for.
If you currently have home or tenant insurance with another company, would you like to get a quote to check for combined policy discounts?
- Yes
- Not applicable - I already have home insurance with the brokerage
- No, I'm not interested
Would you like to increase your policy limit to 2 million?
- Yes - increase to 2 million.
- I would like more than 2 million.
- Not applicable - already at 2 million
- No, not interested
As the costs of bodily injury lawsuits continue to rise, our latest brokerage recommendation is that clients carry at least 2 million liability coverage for auto insurance. The cost increase is fairly low for most clients (about 5%-10%). A personal umbrella policy is also available for higher limits than 2 million.
Please note: this form is for the purposes reassessing upcoming renewals only. No changes will be made until a broker has reviewed and confirmed the potential changes with you. If you require a time-sensitive change to your insurance policy, please call our office immediately.

By clicking "I agree", I consent and authorize my broker, agent or insurer to collect, use and disclose to appropriate third parties personal information as permitted by law for the purposes necessary to quote risks, investigate and settle claims, and detect and prevent insurance fraud, such as credit information, driving record information, and claims history.
Consent:*
- I agree

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Policy Checkup: Auto

Driver Details

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Combined discount and additional coverages

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