Auto Insurance quote request:

Name:

Address:

Postal Code:

Phone Number:

Vehicle(s) Year, Make & Model:

Owned or Leased

Purchase date (year and month)

Vehicle use

Pleasure only:

Kms to work one way:

Business use?

Annual kms:

Driver info:

License number:

Date of Birth:

Date G License:

Date G2 Licensed:

Date G1 Licensed:

Driver Training? :

Any tickets/convictions in the last 3 years?

Any at fault accidents in the last 10 years?

Current Insurance Company:

Expiry date:

How long have you been with your current Insurance company/broker?

Do you use winter tires?

Home Insurance Info:

How long have you been living at this address?

Address including postal code:

Description of Home

Year Built

Detached/Semi- Detached/ Townhome/ Condo?

Number of Stories

Total Square Footage Excluding Basement

Garage

(Attached 1 car/2 car/3 car)

Swimming Pool

Finished Basement

Number of Bathrooms

Number of Fireplaces

Central Air Conditioning

Is the home within 1,000 meters of a fire hydrant? (If you live in the city you probably are)

Discounts

Burglar Alarm: Yes No

Is it monitored by a station? Yes No

Is there a mortgage on the home? Yes No

Your date of birth:

Any smokers in the home?

Have you had any claims in the last five years? Yes No

Details:

Many Insurance companies give a really big discount based on your credit score. In order to get this I just need your consent,

Please confirm. (This will have no effect on your credit) Yes/ No

Are you presently insured?

If so for how many years?

Name of company:

Expiry Date of Coverage:

How long have you been insured with this company/broker?

If the home is over 20 years old please confirm the year updates were done to:

Roof

Plumbing

Electrical

Furnace

Water Heater

Please indicate if you have any of the following to prevent water damage.

Sump pump

Back flow Valve

Septic system

Automatic water shut off