Great Insurance Solutions (Home)

1
Referred by:Skip, if none.
2
Consent to share personal information* This field is required.By affixing my signature below, I AUTHORIZE CONSENT in the collection of my Personal Information. PERSONAL INFORMATION CONSENT As part of my application for insurance, I hereby consent to the brokerage firm named below (the “Broker”) collecting, using and disclosing my personal information, including my insurance and claims history, for purposes of obtaining quotes for me for new or renewal personal lines insurance, property/casualty and/or automobile insurance, as applicable, and to provide such personal information to third parties for this purpose, including to disclose this information to insurance companies and third party insurance rating service providers for the purposes of their assessing risk, determining my eligibility for insurance coverage and setting premiums (“Underwriting Purposes”). I understand that information will be collected directly from me and from third parties such as credit bureaus, the Ministry of Transportation, other insurers and insurance rating service providers. I understand that, for automobile insurance underwriting purposes, some insurers may require up to 25 years of personal information such as driving record and claims history about me and all other permitted drivers and agree to provide the requested information. I represent and warrant that I have obtained consent from the other permitted drivers to also grant this permission in relation to their personal information. I understand that the Broker may be required or permitted to disclose my personal information without my consent pursuant to relevant privacy laws or other laws. The Broker will otherwise handle my personal information in accordance with its privacy policy, which is available on request. If I wish to review personal information pertaining to my application or policy maintained by the Broker, obtain copies of the Broker’s privacy policies or standards, or make other enquiries or express concerns, I understand that I may do so by contacting the Broker’s Privacy Officer. I understand that I may withdraw consent in writing at any time on reasonable notice and that if I do so, the Broker may not be able to provide me with the requested quote(s). I agree that all personal information that I provide to the Broker will be complete and accurate.
Clear
3
Name* This field is required.
First Name
Last Name
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Address* This field is required.
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
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Email* This field is required.
example@example.com
8
What Year did you buy your home?* This field is required.
9
Type of Property* This field is required.
Single Family
Condominium
Town House
Multi Family
Duplex
TriPlex
Rowhouse
Seasonal
Rented Dwelling (income property)
Tenant
Commercial
RV/Trailer
10
Is your basement finished?* This field is required.
Yes
No
Partially
11
Do you have a deck?
YESNO
12
Type of material used on deck
Wood
Synthetic
13
Size of Deck
14
Year Built
15
Square Footage* This field is required.
16
Electrical System* This field is required.
Circuit Breaker
Electrical Fuse
17
Electrical
TYPE
AMPERAGE
DATE UPDATED
18
Heating
TYPE
FUEL SOURCE
DATE UPDATED
19
Plumbing
TYPE
DATE UPDATED
20
Roofing
TYPE
DATE UPDATED
21
Type of Construction* This field is required.
Brick
Concrete
Wood Frame
Concrete Block
22
Do you have an Alarm System?* This field is required.
Yes
No
23
Number of Fireplaces?* This field is required.
24
Number of Bedrooms?* This field is required.
25
Number of Bathrooms?* This field is required.
26
Do you have a pool?* This field is required.
Yes
No
27
Do you have a garage?* This field is required.
Yes
No
28
Have you made a claim in the past 5 years?* This field is required.
Yes
No
29
Your current home insurance carrier?
30
Years Insured:
31
Additional Notes
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: