Privacy, Ownership and Disclosure Statements

To assess your insurance requirements and to serve you as a customer, we need to obtain relevant personal information
about you. Some of this information will come from you and some will come from third parties such as your previous
insurance company or driver licensing authority. To provide you with the most accurate quote, we may need to share some
of this information with prospective insurance companies.

As a brokerage we’re pleased to offer you a choice of insurance solutions from different providers. One such provider is
Intact Insurance. We would like you to know that both Intact Insurance and BrokerLink are both owned by Intact Financial
Corporation

Check here to indicate that you have read and understood the privacy, ownership and disclosure statements above
and agree to the terms as set out.
* Please note that without this agreement, we are unable to continue with the quoting process.

Do we have your permission to use your email to communicate with you about your insurance coverage, send you
helpful insurance tips and ask for your feedback? You may withdrawal your consent at any time.

In order to obtain a potential discount on your property insurance premium, do you consent to a soft credit check?
This is a soft hit and won’t affect your credit score in anyway.
* Your credit score is one of many factors used to assess risk and establish the most suitable insurance offer for your needs, according to your
financial stability. Without this information, we may not be able to offer you the best premium. BrokerLink does not have access to your credit
report, nor does this verification affect your credit score. If you become a client, this information will be updated periodically and used to determine
your potential savings.

Print Name: Ba Hien Nguyen

Signature:

Date: 3/18/2025

BrokerLink.ca
©2020 Brokerlink Inc. ™BrokerLink & Design is a trademark of Brokerlink Inc. All rights reserved.
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Auto
Insurance Quote
Client Information
Name: BaHienNguyen

Address: 4516A 14ST NW Calgary AB; T2K 1J6

Mailing Address: 4516A

14ST NW Calgary AB; T2K 1J6 (if different from above)

Email Address: [email protected] Phone Number: 8254882289

How did you hear about BrokerLink? If referred, by whom?
I heard in from an advertisement.
Date of Birth: 05/29/1973
Occupation Title*: Accountant Name of Employer*:
* Only applicable in Atlantic and Alberta. * Only applicable in Atlantic and Alberta.

If you belong to any groups/associations, please specify along with the membership number:

Name of Current Insurance Company: Not yet. This is our first time buying car insurance
Expiry Date: Date you would like to begin coverage: 3/19/2025

Are you also interested in an property quote? It can save you up to 20%. Yes No

Vehicle # 1
Are you the registered owner of the vehicle? Yes No If not, who?

Who is the primary driver of this vehicle? me

Address where vehicle is located? 4516A 14ST NW Calgary AB; T2K 1J6
Year 2020 Make LEXUS Model NX 300
Serial Number 1TJHARDZ7L2229875
Number of kilometers driven one way to work/school? 10 km Number of Kilometers driven annually? 8000 km
Is there any business or commercial use of your vehicle (e.g. delivery or carry tools or supplies)? Yes No
If yes, explain the use of the vehicle for business use: Uber Other

Number of kilometers driven annually for business use? No. I just only use the car for go to the supermarket.

Purchase Price $40000 Date Purchased 3/12/2025 New Demo Used

Financed Leased Owned

Has the vehicle been modified in any way? (e.g. lifted suspension, engine/performance modifications, wheelchair lift)
Yes No Value of modifications:

Describe modifications:

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Is there any pre-existing damage? Yes No Describe:

Coverages: Liability: $2 million (standard) Above $2 million

Collision: Deductible: $500 $1,000 Above $1,000
Comprehensive: Deductible: $300 $500 $1,000 Above $1,000

Does this vehicle have winter tires?* Yes No Purchase Date 09/2024
* Not applicable in Alberta

Vehicle # 2
Are you the registered owner of the vehicle? Yes No If not, who?

Who is the primary driver of this vehicle?

Address where vehicle is located?

Year Make Model

Serial Number

Number of kilometers driven one way to work/school? Number of Kilometers driven annually?

Is there any business or commercial use of your vehicle (e.g. delivery or carry tools or supplies)? Yes No
If yes, explain the use of the vehicle for business use: Uber Other

Number of kilometers driven annually for business use?

Purchase Price Date Purchased New Demo Used

Financed Leased Owned

Has the vehicle been modified in any way? (e.g. lifted suspension, engine/performance modifications, wheelchair lift)
Yes No Value of modifications:

Describe modifications:

Is there any pre-existing damage? Yes No Describe:

Coverages: Liability: $2 million (standard) Above $2 million

Collision: Deductible: $500 $1,000 Above $1,000
Comprehensive: Deductible: $300 $500 $1,000 Above $1,000

Does this vehicle have winter tires?* Yes No Purchase Date

* Not applicable in Alberta

Driver Info # 1
Driver’s Name: Ba Hien Nguyen
Date of Birth: 05/29/1973 Marital Status: Married Single Retired

License class:
Ontario applicant: Licensed: G1 date G2 date G date
Atlantic & Alberta applicant: First Licensed Date 1/3/2025 First License Date for Motorcycle

Driver’s training: Yes No Date completed: 11/10/2024

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How many years have you continuously held auto insurance? How long with current company?

Have you had a gap in insurance? Yes No When (month/year)

Why?

Any claims / incidence or accidents (at fault, non-fault, vandalism, hail, theft, fire, windshield)?
Alberta applicant, in the past 10 years: Yes No When (month/year)
Ontario applicant, in the past 9 years: Yes No When (month/year)
Atlantic applicant, in the past 6 years: Yes No When (month/year)

Any tickets in the last 3 years (excluding photo radar, red light camera)? Yes No When (month/year)
Type of ticket:

Has your license ever been suspended or cancelled? Yes No When (month/year)

Has an insurance company ever cancelled you for any reason? Yes No When (month/year)
Why?

Is there anyone else living in the household who has a Driver’s License? Yes No

If yes, are they already listed on another insurance policy? Yes No

Driver Info # 2
Driver’s Name:

Date of Birth: Marital Status: Married Single Retired

License class:
Ontario applicant: Licensed: G1 date G2 date G date
Atlantic & Alberta applicant: First Licensed Date First License Date for Motorcycle

Driver’s training: Yes No Date completed:

How many years have you continuously held auto insurance? How long with current company?

Have you had a gap in insurance? Yes No When (month/year)

Why?

Any claims / incidence or accidents (at fault, non-fault, vandalism, hail, theft, fire, windshield)?
Alberta applicant, in the past 10 years: Yes No When (month/year)
Ontario applicant, in the past 9 years: Yes No When (month/year)
Atlantic applicant, in the past 6 years: Yes No When (month/year)

Any tickets in the last 3 years (excluding photo radar, red light camera)? Yes No When (month/year)
Type of ticket:

Has your license ever been suspended or cancelled? Yes No When (month/year)

Has an insurance company ever cancelled you for any reason? Yes No When (month/year)
Why?

Is there anyone else living in the household who has a Driver’s License? Yes No

If yes, are they already listed on another insurance policy? Yes No

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