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Step 3
Driver Information
What is your Date of Birth?
What is your Driver's License number?
What Month/Year did you obtain your licenses?
Did you complete a Driver Training Course?
Are there any another licensed drivers living in your household?
Step 4
Insurance History
Do you currently have an Auto Insurance policy?
How many years have you had auto insurance?
How many years have you been insured with your current company?
Have you been cancelled or declined by an insurance company for any reason in the past 6 years?
Step 5
Claims & Convictions
Have you had any at fault accidents in the last 10 years?
Have you had any tickets in the last 3 years?
Any other losses or claims to report?
Has your license been suspended in the past 6 years for any reason?
Step 6
Vehicle Information
What is the Year, Make & Model of your Vehicle?
Is your Vehicle?
When did you purchase this vehicle?
Was it purchased?
Do you have winter tires?
Do you have any other vehicles to quote?
Step 7
Vehicle Use
How do you use this vehicle?
Do you use your vehicle to commute to Work?
Step 8
More Information
Do you carry passengers for compensation (ridesharing ie: Uber)?
Do you use your vehicle for any Food Delivery Services (ie: UberEats, Skip The Dishes etc) or any other Delivery Service?
Step 9
Other Vehicles/Drivers
I am requesting a quotation for automobile insurance, and I authorize you to collect, use and disclose my driving record, auto insurance history and auto claims history, and those of the listed drivers from whom I declare I have obtained consent for these purposes, as permitted by law for the limited purposes necessary to assess the risk, investigate and settle claims, and detect and prevent fraud.
Please type your Initials in the box below
Step 3
Homeowner Information
What is your Date of Birth?
Are there any additional homeowners that need to be named on the policy?
Step 4
Insurance History
Do you currently have a home insurance policy?
How many years have you had prior Home insurance?
Have you been cancelled or denied by an insurance company in the last three years?
Have you had any claims in the last 6 years?
How many years have you lived at this address?
Step 5
Home Information
What year was your home built?
What type of Home do you have?
How Many Square Feet is your home (excluding the basement & garage)?
What is the distance to the nearest Fire Hydrant?
What is the distance to the nearest Fire Station?
How many stories is your home (excluding basement)?
Step 6
Home Information (Continued)
Type of Construction?
What is the exterior finish? (Choose as many as applicable)
Do you have a basement?
Do you have a swimming pool/hot tub?
Are you on a Septic System?
Do you rent out any portion of your home?
Step 7
Preventative Measures
Do you have a Sump Pump?
Do you have a Back-Flow Preventer?
Does your home have a monitored burglar alarm?
Does your home have a monitored fire/smoke alarm?
Step 8
Updates
What type of roof do you have?
What Year was it last updated/replaced?
What type of Electrical Panel do you have?
What type of Electrical Wiring do you have?
When was your Electrical last updated?
How many Amp service?
Step 9
Updates (Continued)
What type of plumbing do you have? (Check all that apply)
When was your Plumbing last updated?
How is your home heated?
What Year was it last updated/replaced?
What type of Water Heater do you have?
What Year was it last updated/replaced?
Step 10
Home Information
Do you have a Home Based Business?
(Home Office is not considered a Home Based Business)
Is it a Smoke-Free Household?
Do you have a mortgage?
Do you own any other property you would like to get a quote on?
Are you retired?
Please type your Initials in the box below
Step 3
Homeowner Information
What is your Date of Birth?
Are there any additional homeowners that need to be named on the policy?
Step 4
Insurance History
Do you currently have a home insurance policy?
How many years have you had prior Home insurance?
Have you been cancelled or denied by an insurance company in the last three years?
Have you had any claims in the last 6 years?
How many years have you lived at this address?
Step 5
Home Information
What type of building do you live in?
What year was your home built?
How many square feet is your home?
How is your home Heated?
What is the distance to the nearest Fire Hydrant?
What is the distance to the nearest Fire Station?
What floor is your Condo on?
How many floors in the Building?
Step 6
Home Information (Continued)
What is the Estimated Value of your Contents (Personal Belongings) in your Home?
***Minimum amount is $30,000 with most Insurance Companies
***Contents (Personal Belongings) are any of your personally owned items, such as furniture, clothing, electronics, appliances etc)
***Contents (Personal Belongings) are any of your personally owned items, such as furniture, clothing, electronics, appliances etc)
Do you own any other property you would like to get a quote on?
Step 7
Discounts
Does your home have a monitored burglar alarm?
Does your home have a monitored fire/smoke alarm?
Is it a Smoke-Free Household?
Do you have a mortgage?
Are you retired?
Please type your Initials in the box below
Step 3
Homeowner Information
What is your Date of Birth?
Are there any additional renters that need to be named on the policy?
Step 4
Insurance History
Do you currently have Property Insurance?
How many years have you had prior Property insurance?
Have you been cancelled or denied by an insurance company in the last three years?
Have you had any claims in the last 6 years?
How many years have you lived at this address?
Step 5
Home Information
What year was the Home/Building built?
What type of home do you rent?
How Many Square Feet is your home?
What is the distance to the nearest Fire Hydrant?
What is the distance to the nearest Fire Station?
What is the Estimated Value of your Contents (Personal Belongings) in your Home?
***Minimum amount is $30,000 with most Insurance Companies
***Contents (Personal Belongings) are any of your personally owned items, such as furniture, clothing, electronics, appliances etc)
***Contents (Personal Belongings) are any of your personally owned items, such as furniture, clothing, electronics, appliances etc)
Step 6
Discounts
Does your home have a monitored burglar alarm?
Does your home have a monitored fire/smoke alarm?
Is it a Smoke-Free Household?
Are you retired?
Please type your Initials in the box below
Step 3
Personal Information
What is your Date of Birth?
Gender
Do you smoke or use any Nicotine Products (including Vapes & E-Cigarettes)?
Have you ever been diagnosed with a serious health condition?
Step 4
Insurance Products
Are you interested in a Term, Universal or Whole Life ?
How much coverage are you looking for?
Step 2
Company Information
Company Name & Contact Information
What is the Company’s Address?
Step 3
Business Description
Please briefly explain your business
What is the Company’s Gross Annual Revenue?
Are there any US Sales?
Are there any Sales outside of the US & Canada?
Are there any Internet Sales?
Step 4
Business Insurance History
Do you currently have a Commercial Insurance Policy in place for this business?
How many years have you been in business?
Have you been cancelled or denied coverage by an insurance company in the past?
Have you had any claims in the last 6 years?
Step 5
Business Location
Do you Own or Rent your Business Location?
What is the approx. square footage of your location?
What year was the Building/Unit built?
How many stories is your Building/Unit?
How is your Building/Unit Heated?
Are there Sprinklers in your Building/Unit?
Does your Building/Unit have a Monitored Smoke/Fire Alarm?
Does your Building/Unit have a Monitored Burglary Alarm?
Does your Building/Unit have Security Cameras?
Step 6
Updates
What type of roof does your Building/Unit have?
When was it last replaced?
What type of Electrical Panel does your Building/Unit have?
How many Amp service?
What type of Electrical Wiring does your Building/Unit have?
When was the Electrical last updated?
What type of Plumbing does your Building/Unit have? (Check all that apply)
When was the Plumbing last updated?
Step 7
Coverages
What is the total value of all your inventory, equipment, products used to conduct your business?
How much liability would you like to quote?