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Commercial & Business Risk | Life Insurance | Motorcycle Insurance

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Name
Address
Contact Number
Email
Driver Information
Number of Licensed Drivers in Household	1 2 3 4 5
Names of each licensed driver in household
Driver's License No. of Each Driver in Household
#
#
#
#
Do Drivers Under 25 Yrs Old have Driver Training?	Yes No
Driver #2	Yes No
Driver #3	Yes No
Driver #4	Yes No
Driver #5	Yes No
Have you been continuously insured for the past 6 years	Yes No
If not, how many years	1 2 3 4 5
Have you been cancelled for non-payment in the last 3 years?	Yes No
Any accidents or claims in the past 6 years	Yes No
Describe date, amount paid out, and what happened:
List any convictions (all drivers) in the past 3 years
Have any drivers had a Criminal Code conviction in the past 3 years?	Yes No
Are any vehicles used to commute to/from work?	Yes No
Describe vehicle and distance to work (1 way):
Annual kilometers each vehicle has driven - Vehicle #1:	0-5000 kms 5001-15,000 kms 15,001-30,000 kms 30,0001 +
Vehicle #2:	0-5000 kms 5001-15,000 kms 15,001-30,000 kms 30,0001 +
Vehicle #3:	0-5000 kms 5001-15,000 kms 15,001-30,000 kms 30,0001 +
Vehicle #4:	0-5000 kms 5001-15,000 kms 15,001-30,000 kms 30,0001 +
Vehicle #5:	0-5000 kms 5001-15,000 kms 15,001-30,000 kms 30,0001 +
Vehicle Info
Number of vehicles to be quoted	1 2 3 4 5
Vehicle #1
Year
Make (ex. Chevrolet, Honda, etc)
Model (ex. SE, LX, etc.)
Collision Coverage Required	Yes No
Liability Limit Required	$200,000 $500,000 $1,000,000 $2,000,000
Collision Deductible Required	None $250 ded. $500 ded. $1000 ded.
Comprehensive Coverage Required	Yes No
Comprehensive Deductible Required	None $250 ded. $500 ded. $1000 ded.
Vehicle #2
Year
Make (ex. Chevrolet, Honda, etc)
Model (ex. SE, LX, etc.)
Liability Limit Required	$200,000 $500,000 $1,000,000 $2,000,000
Collision Coverage Required	Yes No
Collision Deductible Required	None $250 ded. $500 ded. $1000 ded.
Comprehensive Coverage Required	Yes No
Comprehensive Coverage Required	Yes No
Vehicle #3
Year
Make (ex. Chevrolet, Honda, etc)
Model (ex. SE, LX, etc.)
Liability Limit Required	$200,000 $500,000 $1,000,000 $2,000,000
Collision Coverage Required	Yes No
Collision Deductible Required	None $250 ded. $500 ded. $1000 ded.
Comprehensive Deductible Required	None $250 ded. $500 ded. $1000 ded.
Comprehensive Coverage Required	Yes No
Comprehensive Coverage Required	Yes No
Vehicle #4
Year
Make (ex. Chevrolet, Honda, etc)
Model (ex. SE, LX, etc.)
Liability Limit Required	$200,000 $500,000 $1,000,000 $2,000,000
Collision Coverage Required	Yes No
Collision Deductible Required	None $250 ded. $500 ded. $1000 ded.
Comprehensive Deductible Required	None $250 ded. $500 ded. $1000 ded.
Vehicle #5
Year
Make (ex. Chevrolet, Honda, etc)
Model (ex. SE, LX, etc.)
Liability Limit Required	$200,000 $500,000 $1,000,000 $2,000,000
Collision Coverage Required	Yes No
Collision Deductible Required	None $250 ded. $500 ded. $1000 ded.
Comprehensive Deductible Required	None $250 ded. $500 ded. $1000 ded.
Comprehensive Coverage Required	Yes No

Home Insurance

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Name
Address
Contact Number
Email
Occupancy	Owner occupied Rental unit Vacant property
Year built
Size of ground floor (space, sq. ft)
Estimated replacement cost value/ Current coverage limit on home
Estimated replacement cost value of contents
Primary heat source	Electric Wood Natural Gas Oil Other
Secondary heat source	Electric Wood Natural Gas Oil Other
Do you have a mortgage?	Yes No
Have you been continuously insured for the last 3 years?	Yes No
Liability limit	$200,000 $500,000 $1,000,000 $2,000,000
Deductible	$500 $1,000 $2,500 $5,000
Size of ground floor (square feet)
Type of dwelling	Single Storey Bungalow Split Level Tri-Level 2 storey 1 1/2 storey other
Smokers or Non-smokers in the household?	Smokers Non-Smokers
Any insurance claims?	Yes No
Describe Claims:

Commercial & Business Risk

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Name
Address
Contact Number
Email
Age of building	< 1 year 1-20 years 20-35 years > 35 years
Construction of building	Masonry Frame Non-combustible Fire resistive
Is the building sprinklered?	Yes No
Are you the only tenant?	Yes No
How much area do you occupy?	< 5000 5000-10000 > 10000
Is there a hydrant within 500 ft. (150 metres)?	Yes No
Is there a fire hall within 3 miles (5 kms)?	Yes No
Has insurance ever been denied or canceled?	Yes No
What type of business?	Service Operation Retail Wholesale Operation Building Ownership Farm Office Contractor Manufacturer Garage Operation Other
How many years in the business?	< 1 year 1-5 years > 5 years
Have there been any insurance claims in the last 3 years?	No <=2 >=3
What are the annual receipts?	Up to $50,000 $51,000-$100,000 $101,000-$500,000 $501,000-$1,000,000 Over $1,000,000
What is the annual payroll?	Up to $50,000 $51,000-$100,000 $101,000-$500,000 $501,000-$1,000,000 Over $1,000,000
Additional Info

Life Insurance

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First Name
Last Name
Contact Number	* required
Date of Birth
Sex	Male Female
Are you a smoker?	Yes No
Amount of Insurance Required	$100,000-$250,000 $250,000-$500,000 $500,000-$1,000,000
Any known health problems?	Yes No
Additional Info

Motorcycle Insurance

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Principal Driver Info
Name
Date Of Birth
Date Motorcycle Licensed
Date Automobile Licensed
Approved Motorcycle Driver Training Certificate?	Yes No
Years previous motorcycle insurance
Number of Convictions
Type/Date of convictions
Number of accidents
Type/Date of accidents
Are you a member of a recognized bike organization?	Yes No
If yes, please choose:	HOG (www.harley-davidson.com) <