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Snowmobile Insurance
First Name:
Last Name:
Address:
City:
Province:
Postal Code:
Home Phone Number:
Mobile Phone Number:
Work Phone Number:
Best Time to Contact
Email:
Are you already a client of Raymond Insurance?
Yes     No
Where did you hear about us?
Snowmobile Information:
Year:
Make:
Model:
Ccs:
Current value of snowmobile
(including options and taxes):
Is the snowmobile modified/customized other than cosmetic changes?
Yes     No
If yes please list details:
Is there another snowmobile you would like insured? (If so, please fill in the form again with the other snowmobile(s) information):
Yes     No
Coverage Information :

Liability Limit:

Collision:
Yes     No
Comprehensive:
Yes     No
Specified Perils:
Yes     No
Driver Information:
Date of Birth:
/ /
yyyy   mm   dd
G1 License Date
(if applicable):
/ /
yyyy   mm   dd
G2 License Date
(if applicable):
/ /
yyyy   mm   dd
G License Date:
/ /
yyyy   mm   dd
Do you have a current year trail pass on your snowmobile? (You could get a 10% discount on your insurance if you do):
Yes     No
Minor traffic convictions in the last 3 yrs
Major traffic convictions in the last 3 yrs:
Have you ever had your license suspended in the past 6 years?
Yes     No
Any cancellations of insurance during the past 3 years?
Yes     No
Is there anyone else that would operate the snowmobile?
Yes     No
Insurance Information:
Date insurance is required:
/ /
yyyy   mm   dd
Name of previous insurance company:

Do you have auto insurance?
Yes     No
Do you have home or tenant insurance?
Yes     No
Accident/Claims Information:
Have you had accidents or claims in the past 6 years?

If yes, please list details (date, details of accident, at fault or not at fault, any injuries?)
 
Additional comments:
   
 

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