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 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.