Add a driver
  1. If you would like to add a driver, please complete the form below.

  2. First Name
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  3. Last Name
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  4. Address
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  5. City
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  6. Province
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  7. Postal Code
    Invalid Input
  8. How would you like us to contact you?
    Invalid Input
  9. Daytime Phone
    Invalid Input
  10. Night-time Phone
    Invalid Input
  11. Best Time To Call
    Invalid Input
  12. Email Address
    Invalid Input
  13. Effective Date
    / / Invalid Input
  14. Driver Name
    Invalid Input
  15. Date of Birth
    / / Invalid Input
  16. Gender
    Invalid Input
  17. Marital Status
    Invalid Input
  18. License Number
    Invalid Input
  19. Current class of licence held
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  20. Date you received your G1/G2/G3
    / / Invalid Input
  21. Please give any additional comments you feel appropriate. If you have
    additional informationwhere there was not enough fields above.
  22. Add comments
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  23. First Name
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  24. Last Name
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  25. Current Email Address
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  26. Submit This Form
      
 

DeHart & Stauffer Insurance Brokers Copyright © 2014. All rights reserved.
843 King Street WestOshawa, Ontario L1J 2L4 (905) 576-2234Fax 1-253-550-4655