Car insurance quote requests | Affiliated Insurance

Address:

City:

Any minor driving convictions (speeding, seatbelt, prohibited turn, etc.) in past 3 years:

YesNo

If so (# of convictions):

Any major driving convictions (impaired, careless, distracted driving, etc.) in past 3 years:

YesNo

If so, what type:

How do you use your vehicle:

Pleasure only
Commute to work or school
Business

If you commute, how many kms one way:

Additional vehicles to be quoted (if so, we will gather information in follow-up email):

YesNo

How many years have you continuously 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 not-at-faults claims (windshield, rear-ended, car parked, etc.) within last 10 years:

Was your prior policy canceled for non payment:

YesNo

Was your prior policy canceled for any other reason by the insurance company:

YesNo

I currently:

Own my home
Rent
Live with my parents

Name:
Email:
Address:
City:
Postal Code:
Cell number:
Driver's License # of main driver:
Any minor driving convictions (speeding, seatbelt, prohibited turn, etc.) in past 3 years:	YesNo
If so (# of convictions):
Any major driving convictions (impaired, careless, distracted driving, etc.) in past 3 years:	YesNo
If so, what type:
How do you use your vehicle:	Pleasure only Commute to work or school Business
If you commute, how many kms one way:
Additional vehicles to be quoted (if so, we will gather information in follow-up email):	YesNo
How many years have you continuously 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 not-at-faults claims (windshield, rear-ended, car parked, etc.) within last 10 years:
Was your prior policy canceled for non payment:	YesNo
Was your prior policy canceled for any other reason by the insurance company:	YesNo
I currently:	Own my home Rent Live with my parents
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