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Grey Power Provides
Auto Insurance Estimates
the Easy Way

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At Grey Power, we make it easy to get a quotation for Auto Insurance. If you would like a no obligation quotation, please fill out the form below:

 

The Grey Power

If you submit this completed form, we will email a quote for your Auto Insurance premium. Or, if your prefer, you can reach us at 905-415-1515 and a registered insurance broker will provide a quote over the phone.

Contact Information

Name:
Street:
City:
Province:
Postal Code:
Day Time Telephone Number:
Evening Telephone Number:
Cellular Telephone Number:
Fax Number:
E-Mail Address:
Best time to call:

Expiry date of Current Policy:  

Vehicle Information
Year:
Manufacturer:
Model:
Body type:
Primary use of the vehicle?
If the use is primarily
for commuting to and from
work, what is the distance
one way?

Driver Information

Item Principal Driver Occasional Driver
Date of Birth (YYMMDD)
Sex
Marital Status
Estimated annual driving distance
How many 'at fault' accidents?
(last 6 years)
Date of last 'at fault' accident?
(YYMMDD)
How many 'not at fault accidents'?
(and other claims in the last 6 years)
How many traffic tickets?
(excluding parking in the last 3 years)
Any convictions for careless or dangerous driving, or impaired/blood alcohol level?
in the last 3 years?
Any license suspensions?
(for any reason, in the last 5 years?)
Years licensed in Canada or USA?
Do you have a driver training certificate?
Which statement describes you best?
Continuously insured more than 6 years.
Continuously insured less than 6 years.
Not insured now, had my own policy in the past.
Not insured now, named on someone elses policy in the past.
Have never held auto insurance.
If you are not presently insured, how long has it been since you were?

Months Years

Coverage Information
Liability Limit:
All Perils Deductible:

If you chose an All Perils Deductible, please select 'No Coverage' for Collision, Comprehensive, and Specified Perils deductibles.
Collision Deductible:
Comprehensive Deductible:

If you chose a Comprehensive Deductible, please select 'No Coverage' for the Specified Perils Deductible.
Specified Perils Deductible:

Endorsements
Loss of Use:
Damage to non owned automobiles:
Waiver of Depreciation:

Other Coverage Required
Please describe coverage:

Please enter any questions or comments:

 

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