Auto Insurance Quote Questionnaire

1
NamePlease enter your full legal name
First Name
Last Name
2
Date for Insurance to begin When would you like the effective date of the insurance to be?
Date
Year
Month
Day
3
Do you plan on bundling the policy with a homeowners or tenants policy?
YesNo
4
Phone NumberPlease enter your phone number you can be best reached at
Area Code
Phone Number
5
EmailPlease enter your email address
example@example.com
6
Drivers licenses of anyone driving the vehicle Please list DL# and associated drivers name next to it
Huge
Large
Normal
Small
Ok
Ok
7
Please enter number of vehicles being Insured
8
Please enter the year, make and model of the vehicle including the specific model e.g "2018 Honda Civic EX" (if you have the VIN please enter it)if multiple vehicles list vehicle 1, 2, 3 etc
Huge
Large
Normal
Small
Ok
Ok
9
When car 1 was purchased was it...Condition of vehicle 1 when purchased
New
Used
Demo
10
When car 2 was purchased was it...Condition of vehicle 2 when purchased
New
Used
Demo
11
When car 3 was purchased was it...Condition of vehicle 3 when purchased
New
Used
Demo
12
When car 4 was purchased was it...Condition of vehicle 4 when purchased
New
Used
Demo
13
Purchase date of vehicle 1
Date
Year
Month
Day
14
Purchase date of vehicle 2
Date
Year
Month
Day
15
Purchase date of vehicle 3
Date
Year
Month
Day
16
Purchase date of vehicle 4
Date
Year
Month
Day
17
Is/are the vehicle(s) leased, financed or owned?If leased or financed please provide name and address of lender
Huge
Large
Normal
Small
Ok
Ok
18
Number of KM on vehicle 1 at purchase
19
Number of KM on vehicle 2 at purchase
20
Number of KM on vehicle 3 at purchase
21
Number of KM on vehicle 4 at purchase
22
AddressPlease enter your 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
23
Distance driven daily in KM for vehicle 1
24
Distance driven daily in KM for vehicle 2
25
Distance driven daily in KM for vehicle 3
26
Distance driven daily in KM for vehicle 4
27
Distance driven annually in KM for vehicle 1
28
Distance driven annually in KM for vehicle 2
29
Distance driven annually in KM for vehicle 3
30
Distance driven annually in KM for vehicle 4
31
Winter tires on the vehicle 1?Radials do not count
Yes
No
32
Winter tires on the vehicle 2?Radials do not count
Yes
No
33
Winter tires on the vehicle 3?Radials do not count
Yes
No
34
Winter tires on the vehicle 4?Radials do not count
Yes
No
35
Liability LimitThis is the amount the insurance company would cover you in the case that you are being sued 1m cheaper 2m slightly more expensive
1 Million
2 million
36
Requested deductibleAmount you must pay before insurance company pays out
500
1000
1500
I only want 1 way insurance
37
Where is the vehicle parked at night?(i.e Street, private driveway, garage, condo parking lot, if multiple vehicles list 1,2,3 etc.)
38
Single or Married/Common lawTo qualify as common law must be living with partner for 3 years or 1 year if have children
Single
Married/Common Law
39
License type and date you got it (Please list G1, G2 & G or M etc)(e.g G1 MM/DD/YYYY, G2.......G etc.) *If multiple drivers list name and then classes
Huge
Large
Normal
Small
Ok
Ok
40
First Date you had car Insurance On any policy (could be on a parents policy etc.)
Date
Year
Month
Day
41
With your current insurance company how long have you been with them?Provide date since you started with current company
Date
Year
Month
Day
42
Have you (or any drivers on policy) had any at-fault accidents?If so please list the dates that they happened and the associated driver
Huge
Large
Normal
Small
Ok
Ok
43
Do you (or other drivers on policy) have any tickets you were convicted for?Parking tickets do not count, please provide the offence with as much detail list with associated driver and the conviction date (i.e John Doe, Speeding, 20 over, March 7 2019)
Huge
Large
Normal
Small
Ok
Ok
44
Have you ever been cancelled by an insurance company for non-payment?
YesNo
45
Have you ever had your license suspended?If yes, provide date of suspension, why it was suspended and the date it was reinstated
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: