Pelling Insurance - Online Application

PLAN TYPE:

Classic Plan 20 for Antique & Classic for automobiles 20 years and older

Classic Plan 15 for Special Interest automobiles 15 to 19 years old

Classic Plan 10 for New Collectibles 10 to 14 years old

Custom Plan, 15 years and older

BLANK

_________________________________________

- SECTION 1

Application Information

NAME:

ADDRESS:

CITY/TOWN:

POSTAL CODE:

PHONE (mobile):

PHONE (home):

PHONE (office):

EMAIL:

OCCUPATION:

DRIVER'S LICENCE NUMBER:

DATE OF BIRTH:

YEARS OF DRIVING EXPERIENCE IN CANADA AND USA:

BLANK

_________________________________________

Free Text

Additional Owner Information

APPLICANT:

DRIVERS LICENCE NUMBER:

DATE OF BIRTH:

YEARS OF DVING EXPERIENCE IN CANADA AND USA:

BLANK

_________________________________________

- SECTION 2

Vehicle & Coverage Information

YEAR:

MAKE:

MODEL:

SERIAL NUMBER:

INSURED VALUE

LICENSE PLATE/POLICY NUMBER:

REGISTRATION NUMBER:

CURRENT ODOMETER READING:

DISTANCE DRIVEN PER YEAR:

CURRENT INSURANCE COMPANY:

LICENSE PLATE EXPIRY DATE

Blank

_________________________________________

Photo Upload Section

UPLOAD IMAGE OF VEHICLE - 1:

Upload Photo

UPLOAD IMAGE OF VEHICLE - 2:

Upload Photo

UPLOAD IMAGE OF VEHICLE - 3:

Upload Photo

UPLOAD IMAGE OF VEHICLE - 4:

Upload Photo

UPLOAD IMAGE OF VEHICLE - 5:

Upload Photo

UPLOAD IMAGE OF VEHICLE - 6:

Upload Photo

UPLOAD IMAGE OF VEHICLE - 7:

Upload Photo

UPLOAD IMAGE OF VEHICLE - 8:

Upload Photo

BLANK

_________________________________________

PRIMARY LOCATION OF VEHICLE

Primary Location of Vehicle when Not in Use

LOCATION ADDRESS, CITY, PROVINCE, POSTAL CODE:

IS THE LOCATION RESTRICTED TO THE APPLICANT & MEMBERS OF THE APPLICANT'S HOUSEHOLD?:

Yes

No

DESCRIBE:

CHECK ALL THAT APPLY:

BLANK

_________________________________________

PRIMARY USE VEHICLE:

Primary Use Vehicle information (the vehicle you use on a daily or regular basis)

LICENSE PLATE/POLICY NUMBER:

REGISTRATION NUMBER:

INSURANCE COMPANY FOR PRIMARY VEHICLE:

EXPIRY DATE:

BLANK

_________________________________________

- SECTION 3

Insurance & Claims History (List all losses & claims in the past 6 years)

HAS ANY INSURANCE COMPANY REFUSED TO PROVIDE INSURANCE IN THE PAST 6 YEARS?:

No

Yes

IF YES, INDICATE INSURANCE REFUSAL TYPE:

BY WHICH INSURANCE COMPANY:

LIST ALL LOSSES IN THE PAST 6 YEARS (INCLUDING DATE, CAUSE & AMOUNT PAID:

IF NONE:

CHECK HERE

LIST ALL TRAFFIC CONVICTIONS & DRIVERS LICENCE SUSPENSIONS IN THE PAST 3 YEARS (EXCLUDING PARKING TICKETS)

IF NONE:

CHECK HERE

BLANK

_________________________________________

- SECTION 4

Confirmation & Consent (Acknowledgement / Condition)

CHECK BOX TO ACKNOWLEDGE ACCEPTANCE BY APPLICANT & ADDITIONAL DRIVER

MY VEHICLES WILL BE CHIEFLY used for hobby and/or collector car activities. My vehicle will not be used for regular transportation (i.e. business or to and from work). I have a primary daily use vehicle insured under a separate policy. Insurance becomes effective on payment of the premium, acceptance of risk and completion of full application. All drivers must have 10 years driving experience.

ONLINE APPLICATION

Contact Us

604-263-3400

info@pellinginsurance.com

110-5500 Parkwood Way

Richmond BC V6V 2M4

Privacy Policy

website by cybertech

ONLINE APPLICATION

Contact Us

604-263-3400

info@pellinginsurance.com

110-5500 Parkwood Way

﻿Richmond BC V6V 2M4

Privacy Policy

website by cybertech

Richmond BC V6V 2M4