This document appears to be an underwriting information form for automobile insurance in Chinese. It requests information such as the name of the applicant, address, vehicle details including year/make/model and vehicle identification numbers, principal drivers and their license information, any at-fault accidents or convictions, and any other relevant comments. The purpose is to collect all necessary information from the applicant to underwrite an automobile insurance policy.

1. Underwriting Information for Automobile Insurance 料資保投險保車汔
料資保投險保車汔
料資保投險保車汔
料資保投險保車汔
Name of Applicant / Insured: ：名姓人保投 __________________________________________________________________________________________________________________
Full Address (with postal code): ：碼號區郵及址地 ____________________________________________________________________________________________________________
Insurance Company of most recent automobile insurance:
）稱名紀經是不：意注請（稱名司公險保之保投時現 ___________________________________________________________
Policy Number: ______________________
：日期到單保 Expiry Date:
碼號單保 ______________
Existing Policy Liability Limit: (e.g. $1,000,000):
）額金他其或萬百一幣加 （額險保三第之單保現 e.g. : __________________________________________________________________
Existing Policy Physical Damage Deductible: (e.g. Comp $500, Coll & upset $1,000; OR All perils $1,000):
：）費底墊稱或（額負自之單保現 __________________________________
Number of automobiles in the household or business:
：目數車汔之障保單保現 ___________________________________________________________________________________
How long has the principal driver/registered owner has auto insurance:
：險保車汔買購始開國加在時何於下閣 __________________ years
料資輛車他其上填格表一另用請，部兩過超如，料資車汔之保投所下閣出列表下於請
料資輛車他其上填格表一另用請，部兩過超如，料資車汔之保投所下閣出列表下於請
料資輛車他其上填格表一另用請，部兩過超如，料資車汔之保投所下閣出列表下於請
料資輛車他其上填格表一另用請，部兩過超如，料資車汔之保投所下閣出列表下於請
料資他其
料資他其
料資他其
料資他其
Auto
司公務財之賃租期長 Vehicle Information
稱名商產生及份年車汔 Owned / Leased and date of 途用之輛車部每 者駛駕資車部每
No. YEAR/MAKE/MODEL No. (Serial No.) purchased/leased Lessor (if applicable) Use of vehicle Drivers
Example 稱名商產生及份年車汔 碼號擎引車汔 Owned賃租 ____ Leased
購自 ______ Name 稱名 : Pleasure 閒消物購____________ Principal Driver:
2009 TOYOTA CAMRY 4-DR JF1AB12344D567890 Date purchased
期日買購 : Feb. 25, 2009 Business (
等談洽意生 業商 ) ____________ ：者輛車此駛駕要主
Body Type : Sedan New車手二 __X __車新 Used _____ Address址地 : Commercial 貨送____________ Secondary Driver:
No. of Cylinders/Engine Size: 4 Registered owner other than Commute - one way
數里程單之點地作工返往 10 _ km ：者駛駕位二第
Applicant
車出列請，人保投非 主車冊註如 Estimated Annual Mileage Occasional Driver:
: __________________________
稱名主 : e.g. 20,000 km
數里車行之計估年每 ：者駛駕性歇間
1 稱名商產生及份年車汔 碼號擎引車汔 Owned
賃租 ______ Leased
購自 ______ Name 稱名 : Pleasure ____________
閒消物購 Principal Driver:
Date purchased
期日買購 : ____________ Business ( ) ____________
等談洽意生 業商 ：者輛車此駛駕要主
Body Type
號型 : New車手二 __X __車新 Used _____ Address址地 : Commercial ____________
貨送 Secondary Driver:
No. of Cylinders/Engine Size Registered owner other than Commute - one way
數里程單之點地作工返往 km ：者駛駕位二第
( )
料資 缸汽 擎引 : Applicant
車出列請，人保投非 主車冊註如 Estimated Annual Mileage
車行之計估年每 Occasional Driver:
: ___________________________
稱名主 數里 : ___________________________ ：者駛駕性歇間
2 稱名商產生及份年車汔 碼號擎引車汔 Owned
賃租 ______ Leased
購自 ______ Name 稱名 : Pleasure ____________
閒消物購 Principal Driver:
Date purchased
期日買購 : ____________ Business ( ) ____________
等談洽意生 業商 ：者輛車此駛駕要主
Body Type
號型 : New車手二 __X __車新 Used _____ Address址地 : Commercial ____________
貨送 Secondary Driver:
No. of Cylinders/Engine Size Registered owner other than Commute - one way
數里程單之點地作工返往 km ：者駛駕位二第
( )
料資 缸汽 擎引 : Applicant
車出列請，人保投非 主車冊註如 Estimated Annual Mileage
車行之計估年每 Occasional Driver:
: ___________________________
稱名主 數里 : ___________________________ ：者駛駕性歇間
Driver Information: List all drivers of the described automobile(s) in the household or business
者照執駛駕有持中居家下閣在括包 ，料資者駛駕有所報申格表列下於請
者照執駛駕有持中居家下閣在括包 ，料資者駛駕有所報申格表列下於請
者照執駛駕有持中居家下閣在括包 ，料資者駛駕有所報申格表列下於請
者照執駛駕有持中居家下閣在括包 ，料資者駛駕有所報申格表列下於請 期日照執 取領國加在 G2
Driver 字名者駛駕
字名者駛駕
字名者駛駕
字名者駛駕 碼號照執駛駕
碼號照執駛駕
碼號照執駛駕
碼號照執駛駕 期日照執 取領國加在 G Date when first obtained G2 書證班駛駕有持否是
書證班駛駕有持否是
書證班駛駕有持否是
書證班駛駕有持否是 況狀姻婚
況狀姻婚
況狀姻婚
況狀姻婚
No. Driver Name Driver Licence No. Date 1st licensed in Canada - Class G Lic. Driver Training Certificate Marital Status
1 Yes 是 ____ No 否 _____ Single 身單 Married 婚已 Others 他其
2 Yes 是 ____ No 否 _____ Single 身單 Married 婚已 Others 他其
3 Yes 是 ____ No 否 _____ Single 身單 Married 婚已 Others 他其
4 Yes 是 ____ No 否 _____ Single 身單 Married 婚已 Others 他其
5 Yes 是 ____ No 否 _____ Single 身單 Married 婚已 Others 他其
Are any other persons I the household or business licensed to drive
仕人照執駛駕有持他其有否是司公或居家下閣在，外者駛駕述上除 ? Yes 是 _____ No _____
否
Claims History - any claim or loss in the past 6 years. If so, provide date, details of claim/loss, vehicle/driver & who is responsible for the claim e.g. 100% at fault or 100% NOT at fault, or partially at fault etc.
。等失過犯所者駛駕保投屬否是，料資故事，日、月、年外意出列請，錄記償索之內年六去過在。錄記償賠
Convictions - any conviction e.g. speeding. If so, provide date, description of the conviction and the driver responsible
。 外除車泊例違 駛駕酒醉 速超如，料資票告之到收曾者駛駕位每出列請 , ( )
Any Other comments and/or Information 等裝改否曾如，料資之輛車保投所內單保此關有他其出列請 :
Please add a supplementary page if needed. 。內頁加附於寫填料資將可，要需有 如
S:0 ClientsTCM Personal Line Program2009-10Form - ApplicationInfo Auto Insurance Chinese.xls