Quote Request Form

1

Let's Get Started. How can we address you and send you with your quote?* This field is required.

First Name

Please enter your email

2

Phone Number* This field is required. In case we have any further questions about anything on this quote, we'd love to be able to talk or text with you.

Please enter a valid phone number.

3

What is the effective date of coverage being requested? When do you need this insurance policy to become active?

Date

5

Please tell us about your insurance needs.

6

Location Address of Property

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Is this a new purchase?

YESNO

8

Closing Date

Date

9

Names On DeedAlthough this section has room for four purchasers, if you have less, please leave the remainder of the fields blank.

Full Name of First Insured

Full Name of Second Person

Full Name of Third Person

Full Name of Forth Person

10

Names of InsuredAlthough this section has room for four insured persons, if you have less, please leave the remainder of the fields blank.

Full Name of First Insured

Full Name of Second Person

Full Name of Third Person

Full Name of Forth Person

11

Is this property:Select all that apply

A Principal Residence

A Seasonal Dwelling

Rental Property

Other

12

How much liability coverage are you requesting?

$1,000,000

$2,000,000

13

What deductible do you feel most comfortable with?

$750

$1000

$2500

$5000

14

What Type of home is your property?

1 Story

1 1/2 Story

2 Story

Duplex

15

Tell Us A Bit More About Your Property:

Square Footage

Year Built

History Registry

17

What is the primary siding of your home?

Shingles

Vinyl

Brick

Other

18

Tell us a bit about the roof on this property:

Roof Material

Age of Roofing

19

How many bathrooms does your property have?

# of Full Bathrooms

# of Half Bathrooms

20

Does your property have a porch or deck?

YESNO

21

Tell us a bit about the porch/deck:

Porch Square Feet

Is It Open or Covered?

Deck Square Feet

22

Does your property have a basement?

YESNO

23

Tell us a bit about your basement:

Foundation Type

Finished or Unfinished

Percentage of Basement that is Finished

25

Is your chimney shared or separate?

Shared

Separate

26

Please tell us a bit about your oil tank:

Age of Oil Tank

Type of Oil Tank

Location of Oil Tank

Is any section of the oil line concealed or run under a floor/ground?

27

Are all wood burning appliances certified by ULC/CSA/WH/OTL?

YESNO

28

Tell Us A Bit About Your Chimney:

Type of Chimney

Type of Liner

If Liner is Metal, is it approved?

29

Does Your Property have a monitored alarm system (fire, burglary)?

YESNO

30

Tell Us About The Fire Hall Nearest To Your Property:

Name of Nearest Fire Hall

KM to Nearest Fire Hall

Is There a Fire Hydrant with 300m of your property?

31

Does This Property Have A Trampoline?

YESNO

32

Does The Property Have a Swimming Pool?

YESNO

33

Is There A Mortgagee On This Property?

YESNO

34

Are there any detached structures on this property?This would include sheds, green houses, barns, etc.

YESNO

35

Tell Us About Detached Structure Number 1

Square Footage

Year Built

Type of Heating

Is it Certified?

36

We need to know a bit more about detached structure #1

Type of Siding

Roof Material

Age of Roof / Year

37

Is There Another Detached Structure On This Property?Other structures include sheds, green hosues, barns, shops, etc.

YESNO

38

Tell Us About Detached Structure Number 2

Square Footage

Year Built

Type of Heating

Is it Certified?

39

We need to know a bit more about detached structure #2

Type of Siding

Roof Material

Age of Roof / Year

40

Is there a home-based business operating on this property?

YESNO

41

Please tell us a bit about your business.

42

Have you had any previous insurance claims?

YESNO

43

Please share the details of your previous claims.

44

Please Tell Us A Bit About Your Insurance History:

Name of Previous Insurer

Previous Policy Number

45

Has Your Policy Ever Been Canceled By The Insurer for Any Reason?

YESNO

46

Please Provide Details As To The Reason For Cancellation

47

What is Your Address?

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

48

What's your full name?

First Name

Last Name

49

What is your birth date?

Date

50

Tell Us A Bit About Your Driving Experience:

Driver #1 License No:

Driver #1 Licensed Since:

Is Driver #1 a new driver?

51

Do you have insurance now?

YESNO

52

If no-lapsed coverage how long?

53

Please Tell Us A Bit About Your Auto Insurance History:

Did you have insurance previously?

How many years have you been insured?

Are you listed on somone else's policy?

54

Have you had any accidents, claims, or convictions in the last 6 years?

YESNO

55

Please provide details for any accidents, claims, or convictions you've had in the past six years:

56

Has Your Policy Ever Been Canceled By The Insurer for Any Reason?

YESNO

57

Please Provide Details As To The Reason For Cancellation

58

Tell Us A Bit About Your Daily Vehicle Usage:

What is Your Occupation?

How many kilometers is it from home to work?

59

Is Your Vehicle Used For Business?

YESNO

60

Please provide details of business use:

61

How many kilometers (km) do you drive each year?

# of KM driven for pleasure annually

62

Are there any others to be named on your policy?

YESNO

63

What is the full name of Driver #2?

First Name

Last Name

64

What is Driver #2's birth date?

Date

65

Tell Us A Bit About Driver #2's Experience:

Driver #2 License No:

Driver #2 Licensed Since:

Is Driver #2 a new driver?

66

Are there any more drivers?

YESNO

67

Please Tell Us About Driver #3:

Name of Driver Number #3

Age of Driver #3

If under 25, what sex is Driver #3

If under 25, has Driver #3 completed Drivers Education?

68

Are there any more drivers?

YESNO

69

Please Tell Us About Driver #4:

Name of Driver Number #4

Age of Driver #4

If under 25, what sex is Driver #4

If under 25, has Driver #4 completed Drivers Education?

70

Are there any more drivers?

YESNO

71

What is the Total Number of Drivers in your Household?

72

Please Tell Us About The Vehicle You Wish to Insure:

Vehicle #1 VIN:

Vehicle #1 Make and Model:

Vehicle #1 Year:

Vehicle #1 Principle Driver:

73

Do You Wish To Insure Another Vehicle?

YESNO

74

Please Tell Us About The Second Vehicle You Wish to Insure:

Vehicle #2 VIN:

Vehicle #2 Make and Model:

Vehicle #2 Year:

Vehicle #2 Principle Driver:

75

Do You Wish To Insure A Third Vehicle?

YESNO

76

Please Tell Us About The Third Vehicle You Wish to Insure:

Vehicle #3 VIN:

Vehicle #3 Make and Model:

Vehicle #3 Year:

Vehicle #3 Principle Driver:

77

What Types of Coverage Is Requested:

Full Coverage

Collision

Comprehensive

78

What deductible do you feel most comfortable with?

$250

$500

$1000

79

How much liability coverage are you requesting?

$1,000,000

$2,000,000

80

What is Your Full Name?

First Name

Last Name

81

What Is Your Date of Birth?

Date

82

What is Your Address?

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

83

Tell Us About Your ATV License:

How many years have you been licensed?

What is your Master #?

84

Tell Us About Your ATV:

Type of ATV:

Make / Model:

Serial / VIN #:

Number of CC's:

85

Tell Us About the Drivers:

Who will be the principal driver of the ATV?

Names of Any Additional Adult Drivers

Names of Any Additional Underage Drivers:

86

Tell Us A Bit About The Value Of Your ATV:

When did you purchase this ATV?

What did it cost?

What is your estimated value of this ATV?

87

What Types of Coverage Are Being Requested:

Full Coverage

Collision

Comprehensive

Liabilty