Fillable Application For Own Damage Coverage (ICBC)

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Application For Own Damage Coverage (ICBC)

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The Application For Own Damage Coverage (ICBC) form is 2 pages long and contains:

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  • 17 check-boxes
  • 93 other fields

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File type: PDF

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APV358 (082019)
Page 1 of 2
Application For Own Damage Coverage
The applicant hereby applies under the Insurance (Vehicle) Act and Insurance (Vehicle) Regulation to the Corporation for optional own
damage coverage.
If a policy is issued, it will be on the basis of the information contained in this application, and the application will form part of the policy.
Instructions to Customer: please complete this form and take it to your Autoplan broker who will submit it to ICBC on your behalf.
Complete the following for all applications:
APPLICANT’S SURNAME OR COMPANY NAME (if leased vehicle, name of lessor) GIVEN NAME DRIVER’S LICENCE NUMBER
B.C. RESIDENT?
YES NO
PHONE NUMBER
APPLICANT’S FULL MAILING ADDRESS STREET CITY PROV POSTAL CODE
SECOND APPLICANT’S NAME OR COMPANY NAME GIVEN NAME DRIVER’S LICENCE NUMBER
B.C. RESIDENT?
YES NO
PHONE NUMBER
IF LEASED VEHICLE, NAME OF LESSEE (surname followed by given name[s]) DRIVER’S LICENCE NUMBER
B.C. RESIDENT?
YES NO
PHONE NUMBER
LESSEE'S FULL MAILING ADDRESS STREET CITY PROV POSTAL CODE
SECOND LESSEE’S NAME OR COMPANY NAME GIVEN NAME DRIVER’S LICENCE NUMBER
B.C. RESIDENT?
YES NO
PHONE NUMBER
Vehicle to be insured
YEAR MAKE MODEL BODY STYLE DECLARED VALUE (including taxes)
$
LICENCE PLATE NUMBER (if licensed) REGISTRATION NUMBER VIN
IS EXISTING INSURANCE AND A VEHICLE LICENCE
BEING TRANSFERRED TO THIS VEHICLE?
YES NO
EXISTING LICENCE PLATE NUMBER
WILL VEHICLE BE ON A FLEET?
YES NO
IF YES, FLEET NUMBER FLEET EXPIRY DATE AEB
YES NO
LOW-KM DISCOUNT
YES NO
ANTI-THEFT DEVICE
YES NO
Primary Vehicle Operator (person who will operate the vehicle the most during the policy term)
PRIMARY VEHICLE OPERATOR'S SURNAME GIVEN NAME(S) DRIVER’S LICENCE NUMBER & JURISDICTION
The applicant must list all other persons who may operate the vehicle (attach separate sheet if necessary)
NAME DRIVER’S LICENCE NUMBER & JURISDICTION BIRTHDATE IF NO BCDL (ddmmyyyy) B.C. RESIDENT?
YES NO
NAME DRIVER’S LICENCE NUMBER & JURISDICTION BIRTHDATE IF NO BCDL (ddmmyyyy) B.C. RESIDENT?
YES NO
NAME DRIVER’S LICENCE NUMBER & JURISDICTION BIRTHDATE IF NO BCDL (ddmmyyyy) B.C. RESIDENT?
YES NO
1. Any policy issued pursuant to this application will not provide coverage, other than coverage in the event of theft, ifthevehicle is
operated by any person (including a household member) who is not
• listed on this application,
• approved by the Corporation, and
• listed as a driver in the Special Terms and Conditions which form part of the policy.
2. Note that there is no coverage in the event of theft of the vehicle by an employee or a member of the household of the applicant
(or of the lessee if the vehicle is a leased vehicle), whether or not the person is listed as an approved driver.
APV358 (082019)
Page 2 of 2
Insurance
Intended use (e.g. to and from work, business, pleasure use only, storage, etc.):
Term(s) requested:
Coverages requested: Collision Comprehensive Specied 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 ofcer 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.
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Application For Own Damage Coverage (ICBC)

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Completed 11 February 2021

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