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Type of Insurance*

Type of Auto Insurance*

Type of Home Insurance*

Type of Recreational Insurance*

Type of Life Insurance*

Type of Business Insurance*

Type of Farm Insurance*

Business Insurance Type*

Total value of your contents, tools, equipment?

Description of Operations

Does your business perform any of the following?

• Tattooing including permanent makeup.
• Varicose and spider vein removal.
• Weight loss or cellulite treatments.
• Wrinkle removal or contouring.
• Collagen or botox injections.
• Hair implants.
• Body piercing.
• Dermabrasion or microdermabrasion.
• Unlicensed massage.
• Sale of diet, herbal or nutritional supplements

Yes
No

Have you been continuously licensed for at least 9 years?

If No , we cannot write your policy for you.

Do you have another primary vehicle other than your classic vehicle?*

If No , we cannot write your policy for you.

Year

Make

Model of primary vehicle

Who is your primary vehicle currently insured with?*

Are you retired?

Do you have any tickets or convictions in the last 3 years?

Do you have any claims in the last 6 years?

Do you have any cancellations for non-payment in the last 5 years?

Have you completed a certified driver training course?

Have you ever been listed as a driver on an auto insurance policy?

Are you an existing McDougall Insurance client?

Name*

Company Name*

Date of Birth*

Email*

Phone*

Address*

City*

Province & Postal Code*

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