Auto Insurance Quote

Getting an Auto Insurance Quote is simple and convenient from the comfort of your own home. Simply complete the Auto Insurance Quote Form below, hit Submit, and one of our experienced Brokers will run a personalized quote to find you the best possible price available for a policy that meets your needs and connect with you personally to review your options… it’s that easy.

Alternatively, you can also call us direct during regular office hours at 403.225.5996 to speak with one of our Brokers in person!

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General Quote Information

General information for the primary contact for this quote

How did you hear about A M Luken Insurance?*

Name of the person that referred you (we like to pass on a thank you)

If Other, please let us know how

Which of our Brokers were you looking to connect with?*

Name of Primary Contact*

First Last

Risk Address*

The address for where the vehicle(s) are parked/garaged at night.

Street Address City Province Postal Code

Primary Phone Number*

Secondary Phone Number

Email*

Preferred way to contact you*

Phone

Best time to contact you*

Number of Drivers in the home*

Total number of Driver's in the home for which this quote is applicable

Please enter a number from 1 to 6.

Driver 1 Information

Please fill in the information required below for Driver Number 1

Driver 1 Name*

First Last

Date of Birth*

Gender*

Male

Female

Marital Status*

Single

Married

Common-Law

Occupation*

Do we have permission to retrieve your prior Insurance information?*

By providing your AB Driver's License number, you are hereby authorizing us to retrieve your prior insurance information, including those of any previously listed drivers from whom you have obtained consent, in order to provide you a faster, more accurate quote.

Yes

Driver's License Number*

Class of Driver's License*

Note - Check all that apply

Class 1 (Semi)

Class 2

Class 3

Class 4

Class 5

Class 6 (Motorcycle)

Class 7 (Learners Permit)

First year Licensed in Canada for each Class selected above*

(example: Class 5 in 1995, Class 6 in 2007)

Out of Country License Information

Provide relevant Licensing information from outside of Canada including country licensed and original date of issue. This information may be helpful and documentation may be required to validate history

Driver Training Course completed?*

Certified Driver Training Courses consist of applied learning in class as well as on road instruction. A Certificate of Completion will be required if the DTC Discount is applicable and used as part of rating.

Yes

Do you currently have an Auto Insurance policy in force?*

Yes

When is the Renewal/Expiry Date

Years of continuous Auto Insurance*

Starting from the first time you had your own policy or, were listed on a parents policy etc.

Please enter a number from 0 to 50.

Any Gaps/Lapses in Insurance History?

If Yes, please indicate the date and duration for any gaps in coverage

Have you been previously Cancelled by any Insurance Company for any reason?*

Insurance Companies can cancel for a number of reasons including Non-Payment, Misrepresentation, etc.

Yes

If you were cancelled for Non-Payment, is there any money owing for Time on Risk?*

Yes

Unsure

Cancelled for another reason

Claims Information*

Have you had any claims of any type in the past 10 years?

Yes

Please provide claim(s) details below*

Include the date of the Loss, type of Loss (Collision, Hail, Theft, etc.) and whether or not it was deemed as an At-Fault Loss or not (for collision claims).

Conviction Information*

Have you had any moving violations such as Speeding, Distracted Driving, Dangerous Driving, Failure to obey Traffic Signal, Careless Driving etc. in the past 3 years?

Yes

Please provide conviction(s) details below*

Please provide the conviction date and the type of conviction. IMPORTANT - insurance companies will go back three years from today and will be looking for the Conviction Date, NOT the Offense Date

Has your License been Suspended anytime in the past 6 years?*

Yes

Please provide license suspension details below*

Please include the date, duration and reason for suspension(s)

Is there another Driver to be included on this quote?*

If yes, please fill in Driver 2 Information

Yes

Driver 2 Information

Please fill in the information required below for Driver Number 2

Driver 2 Name*

First Last

Date of Birth*

Gender*

Male

Female

Relationship to Driver 1*

Spouse

Child

Other Relative

Roommate

Other

Occupation*

Class of Driver's License*

Note - Check all that apply

Class 1 (Semi)

Class 2

Class 3

Class 4

Class 5

Class 6 (Motorcycle)

Class 7 (Learners Permit)

First year Licensed in Canada for each Class selected above*

(example: Class 5 in 1995, Class 6 in 2007)

Out of Country License Information

Driver Training Course completed?*

Yes

Years of continuous Auto Insurance*

Starting from the first time you had your own policy or, were listed on a parents policy etc.

Please enter a number from 0 to 50.

Any Gaps/Lapses in Insurance History?

If Yes, please indicate the date and duration for any gaps in coverage

Claims Information*

Have you had any claims of any type in the past 10 years?

Yes

Please provide claim(s) details below*

Include the date of the Loss, type of Loss (Collision, Hail, Theft, etc.) and whether or not it was deemed as an At-Fault Loss or not (for collision claims).

Conviction Information*

Have you had any moving violations such as Speeding, Distracted Driving, Dangerous Driving, Failure to obey Traffic Signal, Careless Driving etc. in the past 3 years?

Yes

Please provide conviction(s) details below*

Please provide the conviction date and the type of conviction. IMPORTANT - insurance companies will go back three years from today and will be looking for the Conviction Date, NOT the Offense Date

Has Driver 2's License been Suspended anytime in the past 6 years?*

Yes

Please provide license suspension details below*

Please include the date, duration and reason for suspension(s)

Is there another Driver to be included on this quote?*

If yes, please fill in Driver 3 Information

Yes

Driver 3 Information

Please fill in the information required below for Driver Number 3

Driver 3 Name*

First Last

Date of Birth*

Gender*

Male

Female

Relationship to Driver 1*

Spouse

Child

Other Relative

Roommate

Other

Occupation*

Class of Driver's License*

Note - Check all that apply

Class 1 (Semi)

Class 2

Class 3

Class 4

Class 5

Class 6 (Motorcycle)

Class 7 (Learners Permit)

First year Licensed in Canada for each Class selected above*

(example: Class 5 in 1995, Class 6 in 2007)

Out of Country License Information

Driver Training Course completed?*

Yes

Years of continuous Auto Insurance*

Starting from the first time you had your own policy or, were listed on a parents policy etc.

Please enter a number from 0 to 50.

Any Gaps/Lapses in Insurance History?

If Yes, please indicate the date and duration for any gaps in coverage

Claims Information*

Have you had any claims of any type in the past 10 years?

Yes

Please provide claim(s) details below*

Include the date of the Loss, type of Loss (Collision, Hail, Theft, etc.) and whether or not it was deemed as an At-Fault Loss or not (for collision claims).

Conviction Information*

Have you had any moving violations such as Speeding, Distracted Driving, Dangerous Driving, Failure to obey Traffic Signal, Careless Driving etc. in the past 3 years?

Yes

Please provide conviction(s) details below*

Please provide the conviction date and the type of conviction. IMPORTANT - insurance companies will go back three years from today and will be looking for the Conviction Date, NOT the Offense Date

Has Driver 3's License been Suspended anytime in the past 6 years?*

Yes

Please provide license suspension details below*

Please provide the date, duration and reason for suspension(s)

Is there another Driver to be included on this quote?*

If yes, please fill in Driver 4 Information

Yes

Driver 4 Information

Please fill in the information required below for Driver Number 4

Driver 4 Name*

First Last

Date of Birth*

Gender*

Male

Female

Relationship to Driver 1*

Spouse

Child

Other Relative

Roommate

Other

Occupation*

Class of Driver's License*

Note - Check all that apply

Class 1 (Semi)

Class 2

Class 3

Class 4

Class 5

Class 6 (Motorcycle)

Class 7 (Learners Permit)

First year Licensed in Canada for each Class selected above*

(example: Class 5 in 1995, Class 6 in 2007)

Out of Country License Information

Driver Training Course completed?*

Yes

Years of continuous Auto Insurance*

Starting from the first time you had your own policy or, were listed on a parents policy etc.

Please enter a number from 0 to 50.

Any Gaps/Lapses in Insurance History?

If Yes, please indicate the date and duration for any gaps in coverage

Claims Information*

Have you had any claims of any type in the past 10 years?

Yes

Please provide claim(s) details below*

Include the date of the Loss, type of Loss (Collision, Hail, Theft, etc.) and whether or not it was deemed as an At-Fault Loss or not (for collision claims).

Conviction Information*

Have you had any moving violations such as Speeding, Distracted Driving, Dangerous Driving, Failure to obey Traffic Signal, Careless Driving etc. in the past 3 years?

Yes

Please provide conviction(s) details below*

Please provide the conviction date and the type of conviction. IMPORTANT - insurance companies will go back three years from today and will be looking for the Conviction Date, NOT the Offense Date

Has Driver 4's License been Suspended anytime in the past 6 years?*

Yes

Please provide license suspension details below*

Please include the date, duration and reason for suspension(s)

Vehicle 1 Information

Fill in the information required below for Vehicle Number 1

Year of Vehicle 1*

Make of Vehicle*

Model of Vehicle*

VIN (Vehicle Identification Number)

The VIN (Serial Number) will help us identify the exact vehicle model you own, or are purchasing, and therefore help us provide you with a more accurate quote. If you have it available, please enter it below.

Is this vehicle used to commute to and from Work or School?*

Yes

How many kilometers is the commute one way?*

Is this vehicle used for Business purposes?*

Ex. Real Estate Agent, Mortgage Broker, etc.

Yes

What percentage of use is allocated for Business use*

Approximately, how many Kilometers do you drive this vehicle annually?*

Vehicle 1 Coverage Information

Select the Coverages and/or Limits below that you would like quoted for Vehicle 1

Third Party Liability Coverage*

Select the Liability Limit below that you would like quoted

Collision Coverage - Deductible Amount*

Collision covers damage to your vehicle when you have an at-fault claim and Hit & Run claims

Comprehensive Coverage - Deductible Amount*

Comprehensive covers things such as Fire, Theft, Hail, Vandalism, Impact with an Animal, etc.

Available Endorsements*

Select all that you would like included in your quote

SEF 13D - Limited Glass

SEF 20 - Loss of Use

SEF 27 - Non-Owned Auto (Rental Car Coverage)

SEF 39 - Accident Forgiveness

SEF 43R - Limited Waiver of Depreciation (newly purchased vehicles only)

SEF 44 - Family Protection

Minor Conviction Waiver

Disappearing Deductible

Does this Vehicle have any previous unrepaired damage?*

Yes

Please provide details of unrepaired damage*

Be sure to include the type of damage (ex. hail, collision, vandalism, etc.) and all locations on the vehicle the damage exists

Is there another Vehicle to add to this quote?*

If yes, please fill in the information for Vehicle Number 2

Yes

Vehicle 2 Information

Fill in the information required below for Vehicle Number 2

Year of Vehicle 2*

Make of Vehicle*

Model of Vehicle*

VIN (Vehicle Identification Number)

Is this vehicle used to commute to and from Work or School?*

Yes

How many kilometers is the commute one way?*

Is this vehicle used for Business purposes?*

Ex. Real Estate Agent, Mortgage Broker, etc.

Yes

What percentage of use is allocated for Business use*

Approximately, how many Kilometers do you drive this vehicle annually?*

Vehicle 2 Coverage Information

Select the Coverages and/or Limits below that you would like quoted for Vehicle 2

Third Party Liability Coverage*

Select the Liability Limit below that you would like quoted

Collision Coverage - Deductible Amount*

Collision covers damage to your vehicle when you have an at-fault claim and Hit & Run claims

Comprehensive Coverage - Deductible Amount*

Comprehensive covers things such as Fire, Theft, Hail, Vandalism, Impact with an Animal, etc.

Available Endorsements*

Select all that you would like included in your quote

SEF 13D - Limited Glass

SEF 20 - Loss of Use

SEF 27 - Non-Owned Auto (Rental Car Coverage)

SEF 39 - Accident Forgiveness

SEF 43R - Limited Waiver of Depreciation (newly purchased vehicles only)

SEF 44 - Family Protection

Minor Conviction Waiver

Disappearing Deductible

Does this Vehicle have any previous unrepaired damage?*

Yes

Please provide details of unrepaired damage*

Be sure to include the type of damage (ex. hail, collision, vandalism, etc.) and all locations on the vehicle the damage exists

Is there another Vehicle to add to this quote?*

If yes, please fill in the information for Vehicle Number 3

Yes

Vehicle 3 Information

Fill in the information required below for Vehicle Number 3

Year of Vehicle 3*

Make of Vehicle*

Model of Vehicle*

VIN (Vehicle Identification Number)

Is this vehicle used to commute to and from Work or School?*

Yes

How many kilometers is the commute one way?*

Is this vehicle used for Business purposes?*

Ex. Real Estate Agent, Mortgage Broker, etc.

Yes

What percentage of use is allocated for Business use*

Approximately, how many Kilometers do you drive this vehicle annually?*

Vehicle 3 Coverage Information

Select the Coverages and/or Limits below that you would like quoted for Vehicle 3

Third Party Liability Coverage*

Select the Liability Limit below that you would like quoted

Collision Coverage - Deductible Amount*

Collision covers damage to your vehicle when you have an at-fault claim and Hit & Run claims

Comprehensive Coverage - Deductible Amount*

Comprehensive covers things such as Fire, Theft, Hail, Vandalism, Impact with an Animal, etc.

Available Endorsements*

Select all that you would like included in your quote

SEF 13D - Limited Glass

SEF 20 - Loss of Use

SEF 27 - Non-Owned Auto (Rental Car Coverage)

SEF 39 - Accident Forgiveness

SEF 43R - Limited Waiver of Depreciation (newly purchased vehicles only)

SEF 44 - Family Protection

Minor Conviction Waiver

Disappearing Deductible

Does this Vehicle have any previous unrepaired damage?*

Yes

Please provide details of unrepaired damage*

Be sure to include the type of damage (ex. hail, collision, vandalism, etc.) and all locations on the vehicle the damage exists

Is there another Vehicle to add to this quote?*

If yes, please fill in the information for Vehicle Number 4

Yes

Vehicle 4 Information

Fill in the information required below for Vehicle Number 4

Year of Vehicle 4*

Make of Vehicle*

Model of Vehicle*

VIN (Vehicle Identification Number)

Is this vehicle used to commute to and from Work or School?*

Yes

How many kilometers is the commute one way?*

Is this vehicle used for Business purposes?*

Ex. Real Estate Agent, Mortgage Broker, etc.

Yes

What percentage of use is allocated for Business use*

Approximately, how many Kilometers do you drive this vehicle annually?*

Vehicle 4 Coverage Information

Select the Coverages and/or Limits below that you would like quoted for Vehicle 4

Third Party Liability Coverage*

Select the Liability Limit below that you would like quoted

Collision Coverage - Deductible Amount*

Collision covers damage to your vehicle when you have an at-fault claim and Hit & Run claims

Comprehensive Coverage - Deductible Amount*

Comprehensive covers things such as Fire, Theft, Hail, Vandalism, Impact with an Animal, etc.

Available Endorsements*

Select all that you would like included in your quote

SEF 13D - Limited Glass

SEF 20 - Loss of Use

SEF 27 - Non-Owned Auto (Rental Car Coverage)

SEF 39 - Accident Forgiveness

SEF 43R - Limited Waiver of Depreciation (newly purchased vehicles only)

SEF 44 - Family Protection

Minor Conviction Waiver

Disappearing Deductible

Does this Vehicle have any previous unrepaired damage?*

Yes

Please provide details for unrepaired damage*

Be sure to include the type of damage (ex. hail, collision, vandalism, etc.) and all locations on the vehicle the damage exists

Additional Information/Comments

Any additional information or details you would like to provide can be entered below.

Consent & Disclosure

As your broker, I am gathering this consent on behalf of the insurer who advises me that: in respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may collect, use and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law and in accordance with our privacy policies.

Authorization*

I authorize you, and on behalf of others listed, to collect, use and disclose to appropriate third parties, this information solely relating to your personal insurance policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settle claims, analyze business results and detect and prevent fraud?*

I Agree

Acknowledgement*

I have reviewed, and confirm that the answers provided in this questionnaire are correct and true to the best of my knowledge and I have not suppressed or misstated any facts. Submitting this form in no way binds any coverage for the Applicant or Company however it is agreed that this form shall become part of the contract should a policy be issued though our agency.

I Agree

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