Ostic Insurance Brokers Limited - Ostic Insurance Brokers

Name(s) of insured(s)
1st insured:
2nd insured:
How can we reach you:
E-mail address:
Daytime telephone #:
Home telephone #:
Fax #:
New Vehicle
Vehicle make:
Year:
Model:
Condition at time of purchase:
Purchase Date:	Date and time
Purchase Price:
VIN (vehicle ID #):
Any non-factory modifications to the vehicle:	YesNo
Any unrepaired damage:	YesNo
If yes, specify:
Is vehicle leased or financed:	YesNo
If yes, specify whether leased or financed:	LeasedFinanced
Names and address of leasing company lien holder:
Use of Vehicle:
Comments (details if use is other):
Kilometers traveled per year:
How many kilometers one-way for daily commute:
Will adding this vehicle result in changes in use of other:	YesNo
Third party Liability coverage requested:
Collision coverage and deductible requested:	none$500$1000Higher
If Higher, please specify:
Comprehensive coverage and deductible requested:	None$300$500Higher
If higher, please specify:
All perils coverage and deductible requested:	None$500$1000Higher
If higher, please specify:
Driver Information (for all drivers who will be operating this vehicle)
Driver #1
Driver:
Date of Birth:	Date and time
Driver type:
Driver #2
Driver:
Date of Birth:	Date and time
Driver type:
Driver #3
Driver:
Date of Birth:	Date and time
Driver type:
Effective Date
When will this change be effective:	Date and timeNow
About Your Insurance (Specify the policy to which this change applies)
Company:
Policy #:
Additional Comments:
Name of your broker:

The Ostic Group