Website
Your Full Name
*
Personal Email Address please?
*
Your personal mobile number?
*
Broker Person Referral Name
Best time to call for 10-15 Min's to discuss quote?
Are you buying auto insurance 1st time in Canada?
YES
NO
Auto Insurance Renewal Date
If you have valid insurance for auto than what is your current brokerage name?
How is your vehicle registered?
Personal - Single Owner
Personal - Joint / Dual Owner
Business / Commercial Name
Leased Vehicle
Financed Vehicle
Current Address or New Address on which you want Insurance quote?
Do you want full insurance or 3rd Party Insurance for your car?
Full Coverage
3rd Party Coverage
Purchase date of current car?
Purchasing car? Please enter VIN, model, and year.
How much KMs you drive to work daily?
Approximately how many kilometers do you drive per year?
Do you use winter tires on your vehicle?
Yes, I use winter tires in winter
No, I don’t use winter tires
Do you use your car for Uber, Uber Eats, or other ride-sharing / delivery services?
Yes, full-time
Yes, part-time
No
Please enter your Ontario Driver’s Licence number
*
Do not enter car plate number
What is your marital status?
Single
Married
Birth Date
What is expiry date of current driving license?
*
Please enter your G1 licence date
Please enter your G2 licence date
Please enter your G licence date
When did you buy your 1st time insurance in Canada?
What is your current annual insurance premium (or renewal amount)?
Do want to add 2nd driver in policy example spouse, brother, friend or parents?Also give license number of person & G1, G2 , G licence date
Any accident or tickets or suspension? please give details with dates
What is your current job title?
Do you currently rent or own your home?
Rent
Own
Do you need tenant/rental home insurance quote also? Always combined auto and tenant/home policy is cheaper
Yes, I’d like to get a quote
No, thanks
What is address you want tenant policy?
When did you buy 1st time tenant or renters or home insurance please give month and year?
If live in apartment/condo how many floors in the building?
What is your current floor you live in building?
Month and year you move to this address?
How many smoke detector in apartment or house?
Anything you want to mention and let us know please write comments?
I agree to the
collection and use of my auto insurance history, driving abstract & personal details by Chase Insurance Brokers and its affiliates.
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