Personal, Auto or Motorcycle
  1. Please send us your information. We will respond to your request within the next 24 hours during business week.

    Vehicle One

  2. Vehicle Type(*)
    Invalid Input
  3. Year(*)
    Invalid Input
  4. Make (*)
    Invalid Input
  5. Model(*)
    Invalid Input
  6. Month & year you purchased your vehicle(*)
    Invalid Input
  7. Registered Owner(*)
    Invalid Input
  8. Is this vehicle used for business?
    Invalid Input
  9. How far is this vehicle driven to work or school or commuter parking lot?(*)
    Invalid Input
  10. Does this vehicle have 4 winter tires which are installed during the winter months?
    Invalid Input
  11. Vehicle Two
  12. Vehicle Type
    Invalid Input
  13. Year of Vehicle
    Invalid Input
  14. Make of Vehicle
    Invalid Input
  15. Model of Vehicle
    Invalid Input
  16. Month & year you purchased your vehicle
    Invalid Input
  17. Registered Owner
    Invalid Input
  18. Is this vehicle used for business?
    Invalid Input
  19. How far is this vehicle driven to work or school or commuter parking lot?
    Invalid Input
  20. Does this vehicle have 4 winter tires which are installed during the winter months?
    Invalid Input
  21. Vehicle Three
  22. Vehicle Type
    Invalid Input
  23. Year of Vehicle
    Invalid Input
  24. Make of Vehicle
    Invalid Input
  25. Model of Vehicle
    Invalid Input
  26. Month & year you pruchased your vehicle
    Invalid Input
  27. Registered Owner
    Invalid Input
  28. Is this vehicle used for business?
    Invalid Input
  29. How far is this vehicle driven to work or school or commuter parking lot?
    Invalid Input
  30. Does this vehicle have 4 winter tires which are installed during the winter months?
    Invalid Input
  31. Effective Date
  32. Start of coverage
    / / Invalid Input

  33. Driver One
  34. First Name
    Invalid Input
  35. Last Name
    Invalid Input
  36. Gender(*)
    Invalid Input
  37. Date of Birth
    / / Invalid Input
  38. When you recieved your G1 licence
    / Invalid Input
  39. When did you receive your G2 licence?
    / Invalid Input
  40. When did you receive your G licence?
    / Invalid Input
  41. Date you completed MTO approved Driver Training
    / Invalid Input
  42. What Class driver's licence do you currently hold?
    Invalid Input

  43. Driver Two
  44. First Name
    Invalid Input
  45. Last Name
    Invalid Input
  46. Gender
    Invalid Input
  47. Date of Birth
    / / Invalid Input
  48. When you recieved your G1 licence?
    / Invalid Input
  49. When did you receive your G2 licence?
    / Invalid Input
  50. When did you receive your G licence?
    / Invalid Input
  51. When you completed MTO apprioved Driver Training
    / Invalid Input
  52. What Class driver's licence do you currently hold?
    Invalid Input

  53. Driver Three
  54. First Name
    Invalid Input
  55. Last Name
    Invalid Input
  56. Gender
    Invalid Input
  57. Date of Birth
    / / Invalid Input
  58. When you recieved your G1 licence?
    / Invalid Input
  59. When did you receive your G2 licence?
    / Invalid Input
  60. When did you receive your G licence?
    / Invalid Input
  61. When you completed MTO apprioved Driver Training?
    / Invalid Input
  62. What Class driver's licence do you currently hold?
    Invalid Input

  63. Driver Four
  64. First Name
    Invalid Input
  65. Last Name
    Invalid Input
  66. Gender
    Invalid Input
  67. Date of Birth
    / / Invalid Input
  68. When you recieved your G1 licence?
    / Invalid Input
  69. When did you receive your G licence?
    / / Invalid Input
  70. When did you receive your G2 licence?
    / Invalid Input
  71. When you completed MTO apprioved Driver Training?
    / Invalid Input
  72. What Class driver's licence do you currently hold?
    Invalid Input
  73. In the last 3 years, has any driver had any tickets (convictions) other than parking tickets?
    Invalid Input
  74. In the last 10 years, has any driver had any accidents?
    Invalid Input
  75. In the last10 years, has any driver had their licence suspended or revoked?
    Invalid Input
  76. Address where vehicles are garaged
    Invalid Input

  77. Insurance History
  78. Have all drivers been listed as drivers on an insurance policy?
    Invalid Input
  79. How long have you been insured with your current insurance company?
    Invalid Input
  80. In the last 10 years, have you had any non-accident insurance claims (like theft or windshield claims)
    Invalid Input
  81. In the last 6 years, has your insurance policy ever been cancelled by an insurance company?
    Invalid Input
  82. Have you ever been convicted of insurance fraud?
    Invalid Input

  83. Saving Opportunities
  84. Do you currently have home insurance?
    Invalid Input
  85. Save up to 12% on your car insurance by insuring your home with us. Would you like to add this multi-line discount to your quote?
    Invalid Input
  86. May we have your consent to use your information for future marketing initiatives and to serve you better?
    Invalid Input
  87. Yearly kilometres driven
    Invalid Input

  88. Your Contact Information
  89. Your Name(*)
    Invalid Input
  90. Phone(*)
    Invalid Input
  91. Email Address(*)
    Invalid Input
  92. Please note Your personal information will be collected and used to provide you with a car insurance quote and of creating a profile in your name. By providing their personal information, you agree that you have obtained their consent for the collection of this information in order to provide you with a car insurance quote.
  93. 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