Quoting Test Page

Primary Insured

Legal Name(Required)

First Last

Date of Birth(Required)

Most companies now offer a potential additional Credit Consent Discount. They perform a search using your name and date of birth which registers as a “Soft Hit” on your credit report. It will not impact your credit rating in any way. This information is not used for any other purpose or shared with any third parties, for any reason, not even us.

Do you consent to a Soft Credit Hit?(Required)

Yes

Are you a member of any of these groups or associations?

Is there a second applicant requiring coverage?(Required)

Yes

Secondary Insured

Legal Name(Required)

First Last

Date of Birth(Required)

Do you consent to a Soft Credit Hit?(Required)

Yes

Are you a member of any of these groups or associations?

General Information

Email(Required)

Phone(Required)

Address of Location to be Insured:(Required)

Street Address Address Line 2 City Province Postal Code

Mailing Address (if different from Location):

Street Address Address Line 2 City Province Postal Code

How long have you lived at this location?(Required)

Please enter a number greater than or equal to 0.

You have just moved in, or have yet to take possession of this location, enter 0

Previous Address (or Current Address if not yet moved):(Required)

Street Address Address Line 2 City Province Postal Code

Are there any smokers in the household?(Required)

Yes

Do you have a Mortgage or Home Equity Line of Credit?(Required)

Yes

Name of Mortgagee or Financial Institution:(Required)

Insurance Information

What type of insurance are you looking for?(Required)

What will be the effective date of the policy(Required)

How many years in total have you continuously carried property insurance?(Required)

If you have not previously carried property Insurance, or your last policy lapsed or cancelled more than 30 days ago, enter 0.

How many years have you been with your current insurer?(Required)

Current Insurance Details

Insurance Company:(Required)

Policy Number:

Deductible:

Premium:

Have you been cancelled, lapsed, or refused insurance in the last 5 years?(Required)

Yes

Please explain why:(Required)

Coverages and Limits

Please indicate the limits on your current policy so that we can provide an “Apples to Apples” quote.

Dwelling Value:

Personal Property:

Sewer Backup:

Identity Theft:

Overland Water:

Home Equipment Breakdown:

Service Line Coverage:

Other coverages:

Claims History

How many claims have you had in the last 10 years?(Required)

Please describe your claims:(Required)

Please include:
• Date of loss
• Cause
• Amount paid
• Is the claim closed?
• Has all damage been repaired?

How would you like to provide the necessary information?(Required)

In order to provide you with an accurate quote, we will need to collect some information on your home or property. You can either complete this information online here, or you can request a phone call from one of our experienced and qualified brokers within one business day.

Yes please call me.

I will provide this information online.

PL – Quote Request Client Info

Primary Insured

Secondary Insured

General Information

Insurance Information

Current Insurance Details

Coverages and Limits

Claims History

Locations