Surveys - Pathway

Group Discount Rates - Select a Company

How did you hear about us?

How would you like us to contact you?

First Name:

Last Name:

Street:

City & Postal Code:

Phone:

Email:

Date of Birth:

List of vehicle

Purchase Date

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

Does this vehicle have winter tires?

Yes No

Do you have any other vehicle(s)

Yes No

Additional Vehicle Information

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.

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.

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:

Enter your response

**Credit information is a factor used in determining discounts for property insurance. This “soft inquiry” has NO impact on your credit score. Do we have consent to run a "soft inquiry"?

Yes No

What is the age of your dwelling? (0-99)

How long have you been with current insurance company?

How long has your property been continuously insured?

Current Property expiry date

Any property claims in the last 5 years?

Yes No

If yes, how many?

Smoke-Free Household?

Yes No

Sump Pump:

Yes No

Do you have a mortgage?

Yes No

Basement finished?

Yes No

Do you run a Business from your home?

Yes No

Do you rent any portion of your home?

Yes No

Notes/Best Time To Call:

Request for Auto & Home Quote