Quote Requests | Combined Home & Auto insurance
Home Quote  
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)
   
Type of Policy:
How many years have you carried property insurance insurance:
Amount of Insurance Required
(Building or Contents Limit):
Current Liability Limit:
Current Deductible:
How far is your location from a fire hydrant?
How far is your location from a fire station?
Is everyone in your household a non-smoker?
Do you have a monitored fire alarm?
Do you have a monitored burglar alarm?
Do you run a business from you home?
How many mortgages are on your property?
Year property was built?
Type of Plumbing:
Type of Wiring:
Type of Heat:
Age of Furnace:
Age of Roof:
Do you have a woodstove?
How many home claims have you had in the past five years?
   
Auto Quote  
Please list all drivers in the household below:
Driver 1  
Name
Birthdate:
Year First Licensed:
Sex:   
Marriage Status:   
Licence Class
Years Continuously Insured:
Number of driving convictions/tickets in the last 3 years:
Has the above driver had any accidents or claims in the past 10 years?
Yes     No
Claims Information:  
 
Claims Date (mm/yyyy) Driver involved
#1:
#2:
#3:
   
Driver 2  
Name
Birthdate:
Year First Licensed:
Sex:   
Marriage Status:   
Licence Class
Years Continuously Insured:
Number of driving convictions/tickets in the last 3 years:
Has the above driver had any accidents or claims in the past 10 years?
Yes     No
   
Claims Information:  
 
Claims Date (mm/yyyy) Driver involved
#1:
#2:
#3:
   
Driver 3  
Name
Birthdate:
Year First Licensed:
Sex:   
Marriage Status:   
Licence Class
Years Continuously Insured:
Number of driving convictions/tickets in the last 3 years:
Has the above driver had any accidents or claims in the past 10 years?
Yes     No
   
Claims Information:  
 
Claims Date (mm/yyyy) Driver involved
#1:
#2:
#3:
   
Driver 4  
Name
Birthdate:
Year First Licensed:
Sex:   
Marriage Status:   
Licence Class
Years Continuously Insured:
Number of driving convictions/tickets in the last 3 years:
Has the above driver had any accidents or claims in the past 10 years?
Yes     No
Claims Information:  
 
Claims Date (mm/yyyy) Driver involved
#1:
#2:
#3:
   
Do driver(s) under 25 years of age have driver training certification?   
   
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:
Current Collision Deductible:
Current Comprehensive Deductible:
Any licence suspensions in past 6 years?   
Any company cancellations in past 6 years?   
Any gaps of insurance in past 6 years?   
Referred By: