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Lant Insurance Brokers

37 Sandiford Drive, Suite 100
Stouffville, ON L4A 7X5

Telephone (905) 640-4111
Fax (905) 640-4450
Toll Free 1-800-461-4099
E-mail info@lant-ins.ca
Website www.lant-ins.ca

Lant Classic Car Insurance Form

For Antique, Classic and Special Interest Automobile Insurance

To apply for insurance coverage please take a few moments to complete the following form.

Applicant Information

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Title:   Mr. Miss Ms. Mrs. *
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1st Driver's Licence No.    *
DOB    *
Date first licenced in Canada  
Years Licenced in Other Countries    
2nd Driver's Name:  
2nd Driver's Licence No.  
2nd Driver - Date first licenced in Canada  
2nd Driver - Years Licenced in Other Countries