Aviva Canada Inc

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Autograph Registration

Contact information form

If you're a safer driver than you get credit for or if you want more control over what you pay for car insurance, please register your interest in Autograph here, by completing a few questions below.

(*) Required information


Title (*)
First name (*)
Last name (*)
Year of birth (dd/mm/yy) (*)
Email address (*)
Re-enter your email (*)
Postal Code (*)
Phone (*)		( ) - x.
Preferred time of day to be contacted by phone
Are you an employee of Aviva or Pilot? (*)		Yes No
Were you referred by an employee of Aviva or Pilot? (*)		Yes No
If you were referred, please enter the name of the Aviva or Pilot employee?
Are there any other drivers in your household? If so, please indicate their year of birth
Driver 2
Driver 3
Automobile 1 (including cars, pick-up trucks, SUVs and minivans
Year (*)
Make (*)
Model (*)
Approximate Km driven annually (*)
Automobile 2 (optional)
Year
Make
Model
Approximate Km driven annually
Name of current insurance company (*)
Name of insurance broker
Month of policy renewal? (*)
By completing the above registration, I understand that a broker familiar with the Autograph program may contact me for a no-obligation quote.