INSURANCE BINDER Automobile Insurance

					INSURANCE BINDER                                                                       FIRM’S CONTACT INFORMATION
Automobile Insurance                                                                   Address:

NAMED INSURED(S)                                                                       INSURER
Name(s):                                                                               Name:
                                                                                       Police no.:
Address:                                                                               Effective date:
                                                                                       Expiry date:

INSURED AUTOMOBILE                                                                     LESSOR/CREDITOR
Year/Make:                                                                             Name:
Identification no.:                                                                    Address:
Use:          Pleasure only                      Business
              Commute                            Commercial
              Occasional business
              Other:                                                                         Purchase        Long-term lease           Contract of leasing

                                                                              Q.F.P. NO. 1
         INSURING AGREEMENTS                                        PERILS                                        AMOUNTS                     DEDUCTIBLES
  Section A                                 Bodily injury to or death of others or damage
  Civil Liability                           to their property
                                                                                                    $                                             n. a.

                                            1. All perils                                                                                 $
  Section B                                 2. Collision or upset                                                                         $
  Loss of or damage
  to insured automobile                     3. Comprehensive (excluding collision or upset)                                               $
                                            4. Specified perils                                                                           $
         Drive Other Automobiles                     Lease or Leasing                         Deletion of Glass                       Loss of Use
                  Q.E.F. 2                                Q.E.F. 5a                               Q.E.F. 13c                   Q.E.F. 20        Q.E.F. 20a
            Notice to Creditor                 Non-owned Automobiles                        Accident Benefits                     Replacement Cost
                 Q.E.F. 23a                    Q.E.F. 27 $                               Q.E.F. 34 $                                   Q.E.F. 43e
                                                            Q.F.P. NO. 5 – REPLACEMENT INSURANCE
                                                                                                                       IMPORTANT STATEMENTS
           CONDITION OF AUTOMOBILE                                              OPTION
                                                                                                                     FOR UNDERWRITING THE RISK
         New automobile                                        Option 1 - Replace the insured automobile
                                                                          through the named dealer
         Demonstration automobile (with no more                Option 2 - Pay an indemnity to replace
         than                  km on the odometer)                        the insured automobile
         Used automobile                                                                                                                                     October 2010
                                                                  ADDITIONAL INFORMATION

Coverages are subject to the premiums, conditions, limits and exclusions of the contract issued by the insurer. This insurance binder will
temporarily replace your insurance policy for a period of         days; your insurance policy will be issued shortly. Coverage remains in effect
conditional on payment of your premium.

By:                                                                  Date :
                    Certified representative’s signature                                                                    Form issued by:

Name:                                                                Telephone :


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