Surveys - Pathway

Auto Quote Questions

Please complete the following questionnaire to obtain an auto insurance quote through our office

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Auto Quote Questions

Name of insureds:

Full Address:

Phone number:

Email:

Current insurance company:

Renewal date:

Number of years with current company:

Number of years continuous auto insurance:

Information for Driver 1:

Name:

Date of Birth:

Driver’s license number:

G license date (approx. month/year):

G2 license date (approx. month/year):

G1 license date (approx. month/year):

Driver Training Completed (approx. month/year):

Convictions in the last 3 years: (If yes: provide date of conviction and what the conviction was for.):

Policy cancellations for non-payment in the last 3 years: (If yes: provide date of cancellation and length of time for gap in coverage:

Driver’s license suspensions in the last 9 years: (If yes: provide date, reason and length of time.):

Claims/accidents in the last 9 years: (If yes: provide date, description and at-fault / not at-fault:

Information for Driver 2:

Name:

Date of Birth:

Driver’s license number:

G license date (approx. month/year):

G2 license date (approx. month/year):

G1 license date (approx. month/year):

Driver Training Completed (approx. month/year):

Convictions in the last 3 years: (If yes: provide date of conviction and what the conviction was for.):

Policy cancellations for non-payment in the last 3 years: (If yes: provide date of cancellation and length of time for gap in coverage:

Driver’s license suspensions in the last 9 years: (If yes: provide date, reason and length of time.):

Claims/accidents in the last 9 years: (If yes: provide date, description and at-fault / not at-fault:

Vehicle 1:

Year/Make/Model:

VIN Number:

Purchase date (approx. month/year):

Leased or financed:

Who is the primary driver of this vehicle:

Vehicle use: (pleasure with no commute to work or commute to work-how many kms one way) :

Estimated annual kms driven:

Winter Tires installed during the winter months:

Vehicle 2: