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This is your Application for Automobile Insurance. Check it carefully and notify your Broker/Agent of any errors or of any changes in the future. Retain this document for your Records. Insurance Coverages Applied For:
Ontario motorists must have the following standard coverages:
Liability, Accident Benefits, Uninsured Automobile and Direct Compensation
Property Damage. You may also purchase additional insurance for Loss or Damage to the automobile and Optional Increased Accident Benefits.
This is a brief explanation of the insurance coverages available to you. For complete details consult your policy. Your Insurer will supply you with a copy of the policy if you request it.
Liability - Provides coverage for you or other insured persons if someone else is killed or injured or their property is damaged in an automobile incident. It will pay for legitimate claims against you or other insured persons up to the limit of your coverage, and the cost of settling claims.
Accident Benefits - Your insurance company is obligated to explain details of Accident Benefits coverage to you.
Provides benefits that you and other insured persons may be entitled to receive if injured or killed in an automobile accident. These benefits include: income replacement for persons who have lost income; payments to non-earners who suffer complete inability to carry on a normal life; payment of care expenses to persons who cannot continue to act as a primary caregiver for a member of their household; payment of medical, rehabilitation and attendant care expenses; payment of certain other expenses; payment of funeral expenses; and payments to survivors of a person who is killed. You may also purchase optional benefits to increase the standard level of benefits provided in your policy.
The optional benefits your insurance company must offer are:
Increased Income Replacement - The standard level of income replacement provided in the policy ($400 per week maximum) may be increased by purchasing optional coverage so that the weekly limit is up to $600, $800 or $1,000. All income replacement benefits are based on 70% of your gross weekly income.
Increased Medical, Rehabilitation and Attendant Care - The standard benefit pays up to $65,000 for medical, rehabilitation and attendant care expenses with a 5 year time limit in most cases. If catastrophically impaired, the standard benefit pays up to $1,000,000 for medical, rehabilitation and attendant care expenses. You may purchase an optional medical, rehabilitation and attendant care benefit of $130,000 or $1,000,000.
Additional Catastrophic Impairment - You may purchase an optional catastrophic impairment benefit of an additional $1,000,000 added to the standard medical, rehabilitation and attendant care benefit or the optional increased medical, rehabilitation and attendant care benefit.
Caregiver Benefit, Housekeeping and Home Maintenance Expenses - The standard benefit for caregiver benefit, housekeeping and home maintenance expenses is available only for a person who is catastrophically impaired. You may purchase an optional benefit to provide these coverages for other impairments.
Death and Funeral - The standard level of death benefits paid to the surviving spouse and dependant of a person who is killed ($25,000 to a surviving spouse and $10,000 to each surviving dependant) may be doubled by purchasing this optional coverage. This coverage also increases the standard funeral expense benefit from $6,000 to $8,000.
Dependant Care - There is no standard dependant care benefit. You may purchase an optional benefit to receive weekly dependant care expenses of $75 for the first dependant, and $25 for each additional dependant, up to $150 per week, for employed persons not receiving a weekly caregiver benefit.
Indexation Benefit - This optional coverage will ensure that certain weekly benefit payments and monetary limits will be adjusted on an annual basis to reflect changes in the cost of living.
Provides coverage if you or other insured persons are injured or killed by an uninsured motorist or by an unidentified (e.g. hit-and-run) driver. It also covers damage to your automobile and its contents caused by an identified, uninsured motorist, subject to a $300 deductible.
Direct Compensation – Property Damage
Provides coverage in Ontario, under certain conditions, for damage to your automobile and to property it is carrying, when another motorist is responsible. It is called Direct
Compensation because you will collect from us, your insurance company, even though you are not at fault for the accident. There may be a deductible amount, and this amount is either paid by you toward the cost of repairs or is deducted from the loss settlement. Higher deductibles may reduce your premium.
Loss or Damage
Provides a selection of optional coverages for your own automobile. Payments cover direct and accidental loss of, or damage to, a described automobile and its equipment. There is usually a deductible amount indicated for each coverage and this amount is either paid by you toward the cost of repairs or is deducted from the loss settlement. Higher deductibles may reduce your premium. There are four types of coverages:
Specified Perils: Covers the described automobile against loss or damage caused by certain specific perils. They are: fire; theft or attempted theft; lightning, windstorm, hail or rising water; earthquake; explosion; riot or civil disturbance; falling or forced landing of aircraft or parts of aircraft; or the stranding, sinking, burning, derailment or collision of any kind of transport in, or upon which, the described automobile is being transported.
Comprehensive: Covers a described automobile against loss or damage other than those covered by Collision or Upset, including perils listed under Specified Perils, falling or flying objects, missiles and vandalism.
Collision or Upset: Covers damage when a described automobile is involved in a collision with another object or tips over.
All Perils: Combines the Collision or Upset and Comprehensive coverages.
For purposes of the Insurance Companies Act (Canada), this document was issued in the course of the insurance company’s insurance business in Canada.
Declaration of Applicant:
I understand that to qualify for a driver’s licence, drivers: must not suffer from any mental, emotional, nervous or physical disability that significantly interferes with the driver's ability to safely drive an automobile of the class they are licensed for; must not be addicted to alcohol or a drug to the extent that it significantly interferes with the driver's ability to safely drive an automobile; and must notify the Ministry of Transportation immediately if the driver becomes physically or mentally disabled to the extent that it might interfere with the driver's ability to safely drive an automobile.
To the best of my knowledge, all listed drivers are qualified to drive and hold a valid driver’s licence, the details I have provided are correct.
My Insurer may require my automobile to be inspected. If I do not co-operate with any reasonable arrangements to inspect my automobile, I understand my optional loss or damage coverages may be cancelled, and any claims under that section may be denied.
Warning - The Insurance Act provides that where:
(a) an Applicant for a contract, (i) gives false particulars of the described automobile to be insured to the prejudice of the Insurer, or (ii) knowingly misrepresents or fails to disclose in the application any fact required to be stated therein; or
(b) the Insured contravenes a term of the contract or commits a fraud; or
(c) the Insured wilfully makes a false statement in respect of a claim under the contract, a claim by the Insured, for other than such statutory accident benefits as are set out in the Statutory Accident Benefits Schedule, is invalid and the right of the Insured to recover indemnity is forfeited.
Warning – Offences
It is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an Insurer in connection with the person’s entitlement to a benefit under contract of insurance, or to wilfully fail to inform the Insurer of a material change in circumstances within 14 days, in connection with such entitlement. The offence is punishable on conviction by a maximum fine of $250,000 for the first offence and a maximum fine of $500,000 for any subsequent conviction.
It is an offence under the federal Criminal Code for anyone to knowingly make or use a false document with the intent it be acted on as genuine and the offence is punishable, on conviction, by a maximum of 10 years imprisonment.
It is an offence under the federal Criminal Code for anyone, by deceit, falsehood or other dishonest act, to defraud or to attempt to defraud an insurance company. The offence is punishable, on conviction, by a maximum of 14 years imprisonment for fraud involving an amount over $5,000 or otherwise a maximum of 2 years imprisonment.
Notice and Consent
I am applying for automobile insurance based on the information provided above. With respect to this application or any renewal or change in coverage, I authorize you to collect, use and disclose my driving record, automobile insurance policy history and automobile insurance claims history as permitted by law for the limited purposes necessary to assess the risk, to investigate and settle claims, and to prevent, detect and suppress fraud. If I am issued an automobile insurance policy or if I make a claim, this information may be pooled with information from other sources and may be subject to analysis for the limited purpose of preventing, detecting or suppressing fraud. For this purpose, the information also may be disclosed to i) fraud prevention organizations, other insurance companies and the police and ii) databases or registers used by the insurance industry to analyze and check information provided against existing information.
I declare that I have obtained consent from the listed drivers to the collection, use and disclosure by you of their driving record, automobile insurance policy history and automobile insurance claims history as described above, I also declare that, prior to permitting any other individuals to drive my automobile, I will obtain consent from such individuals to the collection, use and disclosure by you of their driving record, automobile insurance policy history and automobile insurance claims history also as described above.
I understand that if I have any questions about this consent I am free to consult with my insurance company representative or legal advisor before signing this document.
To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please visit http://www.ibc.ca/en/privacy-terminology.asp.