Home
About Us
Overview
Insurance Partners
Products & Services
Overview
Personal Insurance
Commercial Insurance
Life Insurance
Resources
Overview
Web Links
Insurance Tips
Glossary Of Terms
Claims
Commission Disclosure
Quotes
Overview
Auto Insurance
Home Insurance
Business Insurance
Boat Insurance
Farm Insurance
Trucking Insurance
Recreational Vehicle
Travel Trailer Insurance
Motorcycle Insurance
Contact Us
Overview
Staff Directory
Menu
1.800.263.1520
Let's be friends:
Share:
Get a Quote
Overview
Auto Insurance
Home Insurance
Business Insurance
Boat Insurance
Farm Insurance
Trucking Insurance
Recreational Vehicle
Travel Trailer Insurance
Motorcycle Insurance
Products & Services
Auto Insurance
Name:
Address:
City:
Province:
Postal Code (X1Y 2Z3):
Phone Number (123-456-7890):
Email Address:
Age of principal driver:
Marital status of principal driver:
Married
Single
Number of years licensed for principal driver:
Gender of additional drivers under 25 years of age:
Male
Female
N/A
Do driver(s) under 25 years of age have driver training certification:
Yes
No
Any driving convictions in past 3 years:
Yes
No
If so (# of convictions):
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:
$1,000,000
$2,000,000
Coverage Preferred:
All perils
Collision
Comprehensive
Specified perils
Deductible:
$250
$500
$1,000
Additional vehicles to be quotes:
Yes
No
How many years have you consistently had an auto policy in force or been listed on someone else’s policy as a listed driver:
Number of at fault claims in the past 10 years:
How many years since last at fault claim (if within 10 years):
How many years since last claim? (if within 10 years):
What is your occupation:
How many kilometers do you commute to work 1 way:
Was your prior policy canceled for non payment:
Yes
No
Was your policy lapsed for any other reason by the insurance company:
Which insurance company has your current property insurance:
Security:
Enter security code:
Copyright © 2015 Smith Williams & Bateman - All rights reserved. Created By
AKA Broker