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Intended use (e.g. to and from work, business, pleasure use only, storage, etc.):
Coverages requested: Collision Comprehensive Specied Perils RoadStar
Current odometer reading:
Estimated number of kilometers to be driven during policy term:
Primary location of vehicle when not in use
FULL ADDRESS STREET CITY PROV POSTAL CODE
TYPE OF CONSTRUCTION: CONCRETE METAL WOOD FRAME OTHER — DESCRIBE:
Please attach photo of garage/parking spot.
Check all that apply:
open lot locked re alarm
fenced premises security alarm sprinklers
fully enclosed patrolled lighted
WILL THE VEHICLE BE OPERATED OUTSIDE OF BC ANYTIME DURING THE POLICY TERM? YES — IF YES DESCRIBE: NO
Under section 75 of the Insurance (Vehicle) Act, your claim is invalid if at any time you fail to provide complete and accurate
information, violate a term or condition of your policy or commit fraud. This is a summary. For full information, see section 75 of
the Insurance (Vehicle) Act.
By signing this form, you certify the information contained in this application is correct and authorize the Corporation to conduct further
investigation in relation to this application.
Application must be signed to obtain a quote.
SIGNATURE OF APPLICANT
(if a company, the signature of an authorized ofcer is required)
POSITION HELD (if a company) DATE
SIGNATURE OF SECOND APPLICANT POSITION HELD (if a company) DATE
To be completed by Broker Please complete all broker contact information and submit the application to ICBC as outlined in the
Autoplan Manual, or mail to ICBC Underwriting Services Department (L194300), 151 W Esplanade, North Vancouver, BC V7M 3H9.
AGENCY NAME BROKER ID NUMBER BROKER FAX NUMBER
BROKER CONTACT NAME BROKER CONTACT EMAIL ADDRESS BROKER PHONE NUMBER
Personal information provided on this form is collected under s. 26 of the Freedom of Information and Protection of Privacy Act and will be used for the purpose(s) of assessing
and determining eligibility and premiums for optional coverage on a Special Autoplan Policy. If you have any questions on the collection and use of your personal information,
please call Customer Contact at 604-661-2800 or contact the Manager, Risk Underwriting, at 151 W Esplanade, North Vancouver, BC, V7M 3H9.