Vehicle Information:

Model Year:

Manufacturer:

Model:

Engine CC's:

Vehicle equipped with an anti-theft device?

None Active Anti-Theft Recovery Device Active Rec-Device

Agreed Value of vehicle:

Vehicle use:

Pleasure To/From Work or School Off-Road Use Used for Racing/Speed Contests Parade Business/Commercial Rent or Lease to Others Escort

Is there a LoJack® device installed on this vehicle?

Yes No

Postal Code for the primary location of your vehicle:  

*

Driver Information:

First name:

*

Middle initial:

Last name:

*

Birth date:

(MM/DD/YYYY)*

Gender:

Male Female

Marital status:

Select One Single Separated Married Widowed

Driver's license status:

Valid Permit Suspended Not Licensed Foreign Drivers License

Taken an approved safety course in the past 3 years?

Yes No

Drivers License Number:
(recommended to provide an accurate quote)

Have you had any accidents and/or claims on your insurance in
the last six (6) years?

Yes No

Have you had any tickets (other than a parking ticket) in the
last three (3) years?

Yes No

Have you had your driver's license suspended in the last six (6)
years for any reason?

Yes No

Number of years I have been insured:

Present insurance company:

Quote me replacement Cost coverage as my sled is less than 2 years old:  

Waive the 3% Service fee for OFDC Members:

Yes No

Discounts Information:

Add the OFSC Member discount:

Yes No

My membership number is:

The renewal date is:

Add the 10% additional discount if I decide to insure my House or Car:  

Yes No

House renewal Date:

House Insurance Company:

Address Information:

Mailing address:  

*

Apt./Unit #:

City:

*

Province:

*

Postal code:

*

Email:

*

If you have difficulty in sending this form, please contact us at 1-800-917-7283