Information for Home & Auto Insurance Quotation

What Broker are you working with?(Required)

Referred by:(Required)

Name(s) On Title:

First Name (On Title)

Last Name (On Title)

Date of Birth (1st Owner):(Required)

MM slash DD slash YYYY

Date of Birth (2nd Owner):

MM slash DD slash YYYY

Phone Number:(Required)

Email:(Required)

Preferred Method of Contact:(Required)

Phone

Gender:(Required)

Occupation:(Required)

Home Quote Information

Do you currently have Home Insurance?(Required)

Yes

Current Home Insurance Company:(Required)

Renewal Date:(Required)

MM slash DD slash YYYY

Risk Address:(Required)

Street Address Address Line 2 City Province Postal Code

Have You Moved in the Last 3 Years?(Required)

Yes

Prior Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the Risk Address Also Where You Park Your Car?(Required)

Yes

Dwelling Information

Year Built:(Required)

Foundation Type:(Required)

Poured Concrete

Wood

Crawl Space

Post

Core Floor

Dwelling Style:(Required)

Detached

Semi-Detatched

Townhouse

Mobile / Modular

Seasonal

Rented Dwelling

Number of Stories:

Total Square Footage of the Main Floor:(Required)

Do you have a basement?

Yes

Total Square Footage of Basement:(Required)

Percentage of Basement Complete:(Required)

Total Square Footage of Main Floor & Above:(Required)

Garage

Garage:(Required)

Attached

Detached

None

Age of Garage:(Required)

0-30 Years

30+ Years

Size of Garage (Number of Vehicles):(Required)

What is the main material on the exterior walls of the garage?(Required)

Roof

Year of Roof:(Required)

Roof Type:(Required)

Electrical

Electrical Last Updated (Year):(Required)

Percentage Updated:(Required)

Amp Service:(Required)

Type of Panel:(Required)

Breakers

Fuses

Material of Electrical:(Required)

Plumbing

Plumbing Last Updated (Year):(Required)

Percentage Updated:(Required)

Material Type:(Required)

Type of Water Heater:(Required)

Hot Water Tank

Tankless Water Heat

Heat Pump

Year of Hot Water Tank:(Required)

Heating

Year of Furnace:(Required)

Type of Heating:(Required)

Auxiliary Heating (Backup Heating System):(Required)

Yes

Type of Auxiliary Heating:

Number of Fireplaces:(Required)

Any Wood Burning Stoves?(Required)

Yes

Installed by a Certified Professional?(Required)

Yes

Not Applicable

Water & Septic

Sewer Backup Prevention:(Required)

Sump Pump

Sump Pump with Battery

Backflow Valve

Septic Field

None

Body of Water / Reservoir Within 100 Meters?(Required)

Yes

House Hydrant Protected:(Required)

Yes

Reverse Sloping Driveway:(Required)

Yes

Distance to Closest Responding Firehall:(Required)

Under 5k

Over 5k

Over 13k

Automatic Main Water Shut Off?(Required)

Yes

Number of Sensors:(Required)

Mortgage Information

Mortgage:(Required)

Yes

Number of Mortgages:

Mortgage Lender:(Required)

Second Mortgage Lender:(Required)

Third Mortgage Lender:(Required)

Housing

What is the main material on the exterior walls of the house?(Required)

Occupancy:(Required)

Single Family

Rental Suite

Boarders

Vacant

Air BNB

Number of Full Bathrooms:(Required)

Number of Half Bathrooms:(Required)

Do you have any Patio Decks?(Required)

Yes

Square Footage of Deck:(Required)

Deck Material:(Required)

Build Quality:(Required)

Basic

Standard

Upgrade

Custom

Additional Features (Check all that apply):

Sauna (Wood)

Sauna (Electric)

Swimming Pool

Solarium / Sunroom

Solar Panels / Geothermal

Hot Tub

Additional Features (Other):

Cannabis

Cannabis Plants Grown:(Required)

Underwriting Information

Do you currently have Property Insurance?(Required)

Yes

Who is your current Property Insurance provider?

Number of Years Residing at Residence:(Required)

Number of Years of Continuous Property Insurance:(Required)

Current Deductible:(Required)

Current Liability Limit:(Required)

Renewal Date / Closing Date:(Required)

MM slash DD slash YYYY

Any Claims in the Last 5 Years?(Required)

Yes

Type of Claim:(Required)

Payout ($):(Required)

Any Major Renovations in the Past 5 Years?(Required)

Yes

Describe Renovation Details:

Farming Done on Premises?(Required)

Yes

Describe Type of Farming:

Increased Outbuilding Coverage Required?(Required)

Yes

What Limit is Required?

Home-Based Business?(Required)

Yes

What Type of Business?(Required)

Scheduled Items?

Boat(s)

Jewelery

Vacation Trailer(s)

Fine Art

Other

Total Value of Boat(s):

Total Value of Jewelery:

Total Value of Vacation Trailer(s):

Total Value of Fine Art:

Total Value of Other Scheduled Items:

Describe Details of Scheduled Items:

Is Your Property Over 1 Acre?

Yes

Discount Information

Do you or anyone who resides in the home smoke cigarettes or cannabis?(Required)

Yes

Monitored Security System?(Required)

Yes

Privacy Policy

Consent:(Required)

I agree to the privacy policy.

As your broker, I am gathering this consent on behalf of the insurer who advises me that: In respect of this quotation, we may collect, use and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law. Do you, and on behalf of others listed, authorize us to collect, use and disclose to appropriate third parties, including your broker, this information solely relating to your personal property policy for the purposes necessary to assess the risk, determine a premium, investigate and settle claims, analyze business results and detect and prevent fraud?

Additional Notes or Information

Auto Quote Information

Address:(Required)

Street Address Address Line 2 City Province Postal Code

Do you currently have Auto Insurance?(Required)

Yes

Current Auto Insurance Company:(Required)

Renewal Date:(Required)

MM slash DD slash YYYY

Drivers & Vehicles

How many drivers are there in the household?(Required)

How many vehicles are there in the household?(Required)

Principle Operator (Driver #1)

Name (Principle Operator - Driver #1):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Example: D61014070660905

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #2

Name (Driver #2):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously insured since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #3

Name (Driver #3):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #4

Name (Driver #4):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insurance Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #5

Name (Driver #5):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Driver #6

Name (Driver #6):(Required)

First Last

Driver's License Consent:(Required)

I consent to sharing my driver's abstract history so I may obtain an accurate auto insurance quote. I understand that disclosing my driving history is required before issuing a policy.

Yes

No, please quote me without confirming my driving history.

Driver's License Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Did you obtain your license before 1994?(Required)

Yes

Have you completed Driver Training?(Required)

Yes

Marital Status:(Required)

Gender:(Required)

G1 Acquisition Date:(Required)

MM slash DD slash YYYY

G2 Acquisition Date:(Required)

MM slash DD slash YYYY

G Acquisition Date:(Required)

MM slash DD slash YYYY

Continuously Insured Since:(Required)

MM slash DD slash YYYY

How many at-fault accidents have you been in over the past 9 years?(Required)

How many convictions have you had in the last 3 years?(Required)

How many incidents of misrepresentation or lapse of coverage?(Required)

Have you been cancelled for non-payment in the last ten years?(Required)

Yes

What year was your insurance last cancelled for non-payment?(Required)

Vehicle Information (Vehicle #1)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add more drivers.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #1)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Additional Liability for Damage(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #2)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #2)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Additional Liability for Damage(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #3)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #3)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Additional Liability for Damage(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #4)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #4)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Additional Liability for Damage(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #5)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #5)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Additional Liability for Damage(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Vehicle Information (Vehicle #6)

List the Drivers of this Vehicle:(Required)

First Name

Last Name

Principle Operator or Occasional Driver

Use the "+" icon to add names.

Year:(Required)

Make:(Required)

Model:(Required)

VIN #:

Body Style:(Required)

Parked Postal Code:(Required)

Parking at Night:(Required)

Primary Use:(Required)

Percentage Used For Business:(Required)

Commute Kilometres (One-Way):(Required)

Annual Kilometres:(Required)

Purchase Price:(Required)

Is the Principle Operator of this vehicle the same as the applicant?

Yes

Relationship of the Driver of This Vehicle to the Applicant:

Purchase Date:(Required)

MM slash DD slash YYYY

Do you have Winter Tires?(Required)

Yes

Are your winter tires a separate set of tires installed for the winter months?(Required)

Yes

What is the age of your winter tires (years)?(Required)

Has the vehicle had any after-market modifications or any unrepaired damage?(Required)

Example: lift kit, broke tail light

Yes

Explain the modifications or damage:(Required)

Was this vehicle purchased new or used?(Required)

New

Used

Coverage (Vehicle #6)

In the event of an accident...

Comprehensive(Required)

Do you require coverage for losses related to fire, theft, vandalism, hitting an animal, and weather?

Yes

Collision(Required)

If your vehicle is damaged from colliding with another vehicle or object, will you require coverage for repairs or replacement?

Yes

Additional Accident Benefits(Required)

Do you require any extra coverage for income replacement, rehabilitation, family caregiving expenses, etc?

Yes

Rental Coverage(Required)

Do you require coverage for a rental car?

Yes

Accident Forgiveness(Required)

Do you want to ensure your driving record remains the same with your insurance company?

Yes

Emergency Road Service(Required)

Do you require coverage for costs associated with rescuing you from an unexpected situation such as towing, getting your keys out of a locked vehicle, and repairing flat tires?

Yes

Additional Liability for Damage(Required)

Would you like additional coverage for damages or losses to vehicles your rent or borrow?

Yes

Privacy

Consent(Required)

I agree to the privacy policy.

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 I can access further guidelines on Broker Conduct and the Fair Treatment of Customers online or by request.

I understand that I may withdraw consent 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).

Additional Notes or Information

Phone

This field is for validation purposes and should be left unchanged.

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