Surveys - Pathway

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:

Auto Information:

List 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 any other 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.

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:

Tenant Information

**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)

Is the Property a high-rise?

Yes No

Insurance History Information

How long has your auto been continuously insured?

Current Auto expiry

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

Notes/Best Time To Call:

Colley Insurance

Colley Insurance Request for Auto & Tenant Quote