Quote Requests - Magermans & Raes Insurance Brokers Ltd.

Employer / Group Name:

Name:

Address:

City:

Province:

Postal Code:

(X1Y 2Z3)

Phone Number:

(123-456-7890)

Email Address:

(xxx@yyyy.zzz)

Auto Insurance

Age of principal driver:

Marital status of principal driver:

Number of years licensed
for principal driver:

Gender of additional drivers under 25 years of age:

Do driver(s) under 25 years of age have driver training certification?

Yes No

Any at fault accidents
in past 6 years?

Yes No

Any driving convictions
in past 3 years?

Yes No

Do you use your vehicle
for business?

Yes No

Do you use your vehicle to commute to and from work?

Yes No

Year, make and model of vehicle:

Liability limit requested:

Coverage Preferred:

Policy deductible preferred:

Additional vehicles to be quoted?

Yes No

Home Insurance

Do you own your own home,
own a condo unit or rent?

Homeowner
Condo Owner
Renter

Estimated replacement value of dwelling: (homeowner only)

Estimated replacement value of personal property:
(condo & renters only)

Policy deductible preferred:

Liability amount requested:

Have you had any personal property claimed in the past three years?

Yes No

Identity Theft:

Yes No

Umbrella Liability:

Yes No

Travel Insurance:

Yes No