Contact Information
Name:*
Date of Birth:*
Co-Applicant Name:
Co-Applicant DOB:
Address:*
City:*
Postal Code:*
(X1Y 2Z3)
Phone Number:*
(123-456-7890)
Email Address:*
(xxx@yyyy.zzz)
Home Quote
Property Insurance Renewal:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Type of Policy:*
Homeowners
Condo
Tenant
How many years have you carried property insurance insurance:*
Amount of Insurance Required*
Current Liability Limit:*
$500,000
$1,000,000
$2,000,000
Current Deductible:*
$300
$500
$1,000
How far is your location from a fire hydrant?*
within 300m
further than 300m
How far is your location from a fire station?*
within 8km
within 13km
Is everyone in your household a non-smoker?*
No
Yes
Do you have a monitored fire alarm?*
No
Yes
Do you have a monitored burglar alarm?*
No
Yes
Do you run a business from you home?*
No
Yes
How many mortgages are on your property?*
Year property was built?*
Type of Plumbing:*
Copper
Plastic
Galvanized
Cast iron
Other
Type of Wiring:*
Copper
Aluminum
Knob and Tube
Other
Type of Heat:*
Gas
Oil
Boiler
Electric
Age of Furnace:*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Age of Roof:*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Do you have a woodstove?*
No
Yes
How many home claims have you had in the past five years?*
Auto Quote
Auto Insurance Renewal:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Please list all drivers in the household below:
Driver 1
Name
Birthdate:
Year First Licensed:
Sex:
Male
Female
Marriage Status:
Married
Single
Licence Class
G
G1
G2
Number of driving convictions/tickets in the last 3 years:
0
1
2
3
4
5
Has the above driver had any accidents or claims in the past 10 years?
Claims Information:
Driver 2
Name
Birthdate:
Year First Licensed:
Sex:
Male
Female
Marriage Status:
Married
Single
Licence Class
G
G1
G2
Number of driving convictions/tickets in the last 3 years:
0
1
2
3
4
5
Has the above driver had any accidents or claims in the past 10 years?
Claims Information:
Driver 3
Name
Birthdate:
Year First Licensed:
Sex:
Male
Female
Marriage Status:
Married
Single
Licence Class
G
G1
G2
Number of driving convictions/tickets in the last 3 years:
0
1
2
3
4
5
Has the above driver had any accidents or claims in the past 10 years?
Claims Information:
Driver 4
Name
Birthdate:
Year First Licensed:
Sex:
Male
Female
Marriage Status:
Married
Single
Licence Class
G
G1
G2
Number of driving convictions/tickets in the last 3 years:
0
1
2
3
4
5
Has the above driver had any accidents or claims in the past 10 years?
Claims Information:
Do driver(s) under 25 years of age have driver training certification?
Yes
No
Please list all the vehicles on your policies:
Vehicle 1
Year:
Make:
Model:
Km Driven to Work:
Vehicle 2
Year:
Make:
Model:
Km Driven to Work:
Vehicle 3
Year:
Make:
Model:
Km Driven to Work:
Vehicle 4
Year:
Make:
Model:
Km Driven to Work:
Current Liability Limit:
$500,000
$1,000,000
$2,000,000
Current Collision Deductible:
$100
$300
$500
$1,000
Current Comprehensive Deductible:
$100
$300
$500
$1,000
Any licence suspensions
in past 6 years?
Yes
No
Any company cancellations
in past 6 years?
Yes
No
Any gaps of insurance
in past 6 years?
Yes
No
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