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2
Personal Loan Amount?How much of a loan are you looking for ?
$
$500
$1,000
$2,500
$5,000
$7,500
$10,000
$25,000+
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$
$500
$1,000
$2,500
$5,000
$7,500
$10,000
$25,000+
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Monthly Expense? Total Monthly Expense
4
Method of EntryChoose Method of entry
Take A picture
Manual Entry
5
Driver License Picture* This field is required.
6
Ownership Picture & or VIN #* This field is required.
7
Ownership Property
Home Owner
Condo
Tenant
Revenue Property
8
Business Contact Details
Business Name
Contact Name
Please enter your phone
Please enter your email
Please Select
Please Select
Sole Proprietorship
Partnership
Corporation
Non-Profit
Business Type
Website
9
GenderChoose one
Male
Female
10
Gender Driver #2Choose one
Male
Female
11
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Business Details
Nature of Business
Estimate Annual Income
Please Select
Please Select
0
1
2
3
4
5
6
7+
Number of years with business Insurance
13
Home Cancelations / Laps
Please Select
Please Select
Yes
No
Cancelation for non -payment in the last 3 years?
Please Select
Please Select
0
1
2
3
4
5
6+
Number of cancelations for non-payment in last 3 years?
Please Select
Please Select
1 year
2 years
3 years
4 years
5 years
6 years+
How long at current address?
14
Rating Questions Auto
Please Select
Please Select
Yes
No
Do you have any Non-payment cancellations last 3 years
Please Select
Please Select
0
1
2
3
4
5
6+
If yes how many non-payment cancellation ?
Please Select
Please Select
Private Garage
Private Driveway
Underground Parking
Parking Lot
Carport
Indoor Storage
Street
Other
Where is this vehicle parked overnight?
Please Select
Please Select
Personal
Commute
Business
What is the primary use of this vehicle?
Please Select
Please Select
0 KM
2 KM
5 KM
7 KM
10 KM
15 KM
20 KM
30 KM
40 KM
50 KM
60 KM
70 KM
80 KM
90 KM
100 KM
150 KM
200 KM
How many kilometres are driven to work or school one way (each day)?
Please Select
Please Select
500 KM
1,000 KM
2,000 KM
3,000 KM
4,000 KM
5,000 KM
6,000 KM
7,000 KM
8,000 KM
9,000 KM
10,000 KM
15,000 KM
20,000 KM
25,000 KM
34,000 KM
40,000 KM
50,000 KM
60,000 KM
70,000 KM
80,000 KM
90,000 KM
100,000 KM
How many total kilometres are driven each year
15
Date of Birth
Date
Year
Month
Day
16
Rating Questions
Please Select
Please Select
G
G2
G1
What type of licence does Driver #1 currently hold?
How old was Driver #1 when he was first licenced in Ontario?
Please Select
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
G licence date
Please Select
Please Select
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
Please Select
Please Select
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
When was Driver #1 first listed as a driver on an insurance policy in Canada or the U.S.?
Please Select
Please Select
Not currently insured
1 year
2 years
3 years
4 years
5 years+
How long has Driver #1 been with his or her current insurance company?
17
Mortgage Balance
18
Smoker?Tobacco products in the last 12 months?
Yes
No
19
Type of Drivers Licence* This field is required.Choose current License class?
G
G2
G1
20
Type of Drivers Licence (Driver #2)* This field is required.Choose current License class?
G
G2
G1
21
When did you obtain your current licence?
Date
Year
Month
Day
22
When did Driver #2 obtain your current licence?
Date
Year
Month
Day
23
Driver's Licence Number
24
Driver #2 Licence Number
25
Vehicle DetailsMM/YYYY
Year eg. 2002
Please Select
Please Select
Car
Truck
Van
Motorcycle
Type of Vehicle
Make eg. Honda
Model eg. CIVIC LX
Vin#
Vehicle purchase date
26
Any Claims in the last 5 years?
YESNO
27
Number of Claims
28
Do you have a mortgage?
YESNO
29
Content Value
30
Level of Protection Life
$50,000
$100,000
$250,000
$500,000
$750,000
$1,000,000+
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$50,000
$100,000
$250,000
$500,000
$750,000
$1,000,000+
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Level of Protection Travel
$25,000
$50,000
$75,000
$100,000+
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$25,000
$50,000
$75,000
$100,000+
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3
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Annual Income Range?
$15-$30K
$30-$45K
$45-$60K
$60K+
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3
$15-$30K
$30-$45K
$45-$60K
$60K+
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3
33
What’s your credit rating?
Poor (300 - 619)
Fair (620 - 659)
Good (660 - 719)
Excellent (720 - 850)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3
Poor (300 - 619)
Fair (620 - 659)
Good (660 - 719)
Excellent (720 - 850)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3
34
Living Arrangement
Own
Rent
Other
35
Contact Details* This field is required.
Full Name
Please enter your phone
Please enter your email
Please Select
Please Select
Married
Single
Divorced
Widowed
Marital Status
36
Add Another Driver
YESNO
37
Add Driver Manual Entry
YESNO
38
Driver 2 License Picture* This field is required.
39
Add Another Vehicle
YESNO
40
Vehicle # 2 Ownership Picture* This field is required.
41
Driver #2
Full Name
Date of Birth
Please Select
Please Select
G1
G2
G
Current License?
When did you get your Current License?
Drives License Number
42
Add Another Vehicle Manual Entry
YESNO
43
Vehicle #2Use and Details
Year eg. 2002
Please Select
Please Select
Commute
Pleasure
Business
Vehicle Usage
Make eg. Honda
Model eg. CIVIC LX
Vin#
Vehicle purchase date
44
Notes (if Any)
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: