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Pelling Collector Car Insurance
On-Line Application

Plan Choice (Please Check)

- Classic Plan 20 for Antique & Classic for automobiles 20 years and older,
- Classic Plan 15 for Special Interest automobiles 15 to 19 years old,
- Classic Plan 10 for New Collectibles 10 to 14 years old.
- Custom Plan, 15 years and older.
Section 1 – Applicant Information
Postal Code
Telephone (Home)
Telephone (Office)
Drivers Licence Number
Date of Birth   (DD/MMM/YYYY)
Years of Driving Experience
in Canada and USA
     Additional Owner Information
Drivers Licence Number
Date of Birth   (DD/MMM/YYYY)
Years of Driving Experience in Canada and USA
Section 2 – Vehicle & Coverage Information
Serial Number
Insured Value
Licence Plate / Policy Number
Registration Number
Current Odometer Reading
Distance Driven Per Year
Current Insurance Company
Licence Plate Expiry Date  
     Primary Location of Vehicle When Not In Use
   Location Address, City, Province, Postal Code

Is the location restricted to the applicant & members of the applicant’s household? 

Yes     No - if NO describe

Check all that apply: Fully enclosed garage
Open Lot
Underground parking garage
Self Storage Facility
Premise security alarm
Security patrol
     Primary Use Vehicle information (vehicle you use on a daily or regular basis)
Licence Plate / Policy Number  
Registration Number
Insurance Company For Primary Vehicle
Expiry Date  
Section 3 – Insurance & Claims History      (List all losses & claims in the past 6 years)

Has any Insurance Company Refused to provide insurance in the past 6 Years?    No Yes

If Yes, indicate insurance refusal type     

By which Insurance Company       

List all Losses in the past 6 years (including  Date, Cause & Amount Paid.   

If None check here

List all traffic convictions  & Drivers Licence Suspensions in the past 3 years(excluding parking tickets)

If None check here

Section 4 – Confirmation & Consent         (Acknowledgement / Condition)

Check box to acknowledge acceptance by applicant & additional driver.

MY VEHICLES WILL BE CHIEFLY used for hobby and/or collector car activities. My vehicle will not be used for regular transportation (i.e. business or to and from work). I have a primary daily use vehicle insured under a separate policy. Insurance becomes effective on payment of the premium, acceptance of risk and completion of full application. All drivers must have 10 years driving experience.

Please note that this is an application only, no insurance coverages will apply unless confirmation is issued by Pelling & Associates Insurance Brokers/Consultants Inc.



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