Surveys - Pathway

Colley Auto Questions

First Name

Last Name

City & Postal Code

How did you hear about us?

Google Facebook Friend Other

Email

Phone

Date of Birth (mmm/dd/yyyy)

Auto Information

Vehicle Year, Make & Model (include VIN if you have it)

Purchase Date

Distance Driven 1-way to work/school (km)

Does this vehicle have winter tires?

Yes No

Do you have another vehicle(s)?

Yes No

If yes, Please list the vehicle(s) include VIN if you have it, Purchase Date, Distance driven to work/school (km) & if vehicle(s) have winter tires.

Additional Vehicle Information

Driver Information

By providing my driver’s license number for automobile insurance Underwriting Purposes I hereby authorize the retrieval of 10 years of personal information such as driving record and claims history about me and all other past and present permitted drivers and agree to provide the requested information. I represent and warrant that I have obtained consent from the other permitted drivers to also grant this permission in relation to their personal information.

Yes No

Driver's License#'(s) for ALL drivers in the household (indicate if any drivers have Driving Training)

Date Principle Operator Licensed (include G1, G2 & full G dates)

Do you or any other drivers in the household have any At-Fault Accidents/Claims?

Yes No

If yes, list the date(s) of accident/claims

Do you or any other drivers in the household have any Convictions?

Yes No

If yes, list the date(s) of convictions & type

# of Years Continuously Insured

# of Years with Current Insurance Company

Do you currently have property insurance?

Yes No

How would you like us to contact you?

Email Phone

Notes / Best time to call

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