My Site - H.E. Passingham Insurance Brokers Ltd.

Name:

Address:

City:

Province:

Postal Code:

Phone number:

Email:

Date of Birth:

Do you own your own home or a condo unit:

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 claims in the past three years:

YesNo

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:

YesNo

Any at fault accidents in the past 6 years:

YesNo

Any driving convictions in the past 3 years:

YesNo

Do you use your vehicle for business:

YesNo

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

YesNo

Year, make and model of vehicle:

Liability limit requested:

Coverage Preferred:

Deductible:

Additional vehicles to be quoted:

YesNo

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