Request A Quotation

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PERSONAL INFORMATION

Complete in all cases.
First Name  
Last Name      
Address      
City      
Prov      
Postal Code    
Home #    
Work #    
Cell #    
Fax #    
Email address      
How should we reach you?

    
Do you presently have any type of insurance with Carruthers Nicol Insurance ?

    

Click here to jump to the Home Insurance section. 		 


AUTO INSURANCE QUESTIONS

Complete for auto insurance request.

  
What company are you currently insured with?
    
When does your policy renew?

MM/DD/YYYY		    
Have you had continuous insurance for the past 6 years?
If no explain why.
    
How long have you been with your current insurer?

    
In the past 5 years has an insurance company cancelled or not renewed you?
If yes explan why.



DRIVING RECORD

In the past 6 years have you or anyone in your household had any of the following.
License suspension?

    
If Yes provide details below.
    
Convictions/Speeding
Tickets?

    
If Yes provide details below.
    
Claims?

    
If Yes provide details below.
    
Accidents (whether your fault or not)?

    
If Yes provide details below.
    



DRIVER INFORMATION

Complete for each driver in the household.
Driver name #1    
Relationship to you    
Date of birth
MM/DD/YYYY		    
Date Licensed (G1)
MM/DD/YYYY		    
Date Licensed (G2)
MM/DD/YYYY		    
Date Licensed (G)
MM/DD/YYYY		    


Driver name #2
   
Relationship to you    
Date of birth
MM/DD/YYYY		    
Date Licensed (G1)
MM/DD/YYYY		    
Date Licensed (G2)
MM/DD/YYYY		    
Date Licensed (G)
MM/DD/YYYY		    


Driver name #3
   
Relationship to you    
Date of birth
MM/DD/YYYY		    
Date Licensed (G1)
MM/DD/YYYY		    
Date Licensed (G2)
MM/DD/YYYY		    
Date Licensed (G)
MM/DD/YYYY		    


Driver name #4
   
Relationship to you    
Date of birth
MM/DD/YYYY		    
Date Licensed (G1)
MM/DD/YYYY		    
Date Licensed (G2)
MM/DD/YYYY		    
Date Licensed (G)
MM/DD/YYYY		    


Driver name #5
   
Relationship to you    
Date of birth
MM/DD/YYYY		    
Date Licensed (G1)
MM/DD/YYYY		    
Date Licensed (G2)
MM/DD/YYYY		    
Date Licensed (G)
MM/DD/YYYY		    


Driver name #6
   
Relationship to you    
Date of birth
MM/DD/YYYY		    
Date Licensed (G1)
MM/DD/YYYY		    
Date Licensed (G2)
MM/DD/YYYY		    
Date Licensed (G)
MM/DD/YYYY		    



VEHICLE INFORMATION

Complete for each vehicle to be insured.
Make & Model    
Year    
Use If commuting, enter Kms 1 Way.
If business or commercial describe below.		    
Kms 1 Way    
Describe Use    
Make & Model    
Year    
Use If commuting, enter Kms 1 Way.
If business or commercial describe below.		    
Kms 1 Way    
Describe Use    
Make & Model    
Year    
Use If commuting, enter Kms 1 Way.
If business or commercial describe below.		    
Kms 1 Way    
Describe Use    
Make & Model    
Year    
Use If commuting, enter Kms 1 Way.
If business or commercial describe below.		    
Kms 1 Way    
Describe Use    
Make & Model    
Year    
Use If commuting, enter Kms 1 Way.
If business or commercial describe below.		    
Kms 1 Way    
Describe Use    
Make & Model    
Year    
Use If commuting, enter Kms 1 Way.
If business or commercial describe below.		    
Kms 1 Way    
Describe Use    

Click here to jump to the end of this form.		  



HOME INSURANCE QUESTIONS

Complete for home insurance request.

  
Select the type of home from the list.                   

      
What company are you currently insured with?  
    
When does your policy renew?                          
  

MM/DD/YYYY		    
How long have you been with this insurer?       

    
In the past 5 years has an insurance company cancelled or not renewed you?

    
If Yes explain why.
    
In the past 5 years have you had any property claims?

    
If Yes provide
details below.
    
What is the age of your home?

    
If over 25 years please give year of updates for the following items.    
Heating
YYYY 		     
Plumbing
YYYY 		     
Wiring
YYYY		      
Roof
YYYY		      
If you are happy with your submission, click submit.    
Note: All applicable information must be provided for your request to be considered.
CNII only offers insurance to Ontario residents.		      
Thanks for taking the time to complete this request for quote form. In order for our office to
properly consider your request, we require that you answer all questions fully and accurately.

      



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