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Online Quote Questionnaire:

Basic Information – Part I
Name *
Email *
Address * (w/postal code)
City *
Phone *
Date of Birth
Occupation
Married

Y N

Effective date required


Please choose the category section you are applying for – Part II
AUTO / RV / Motorcycle:
Year/Make/Model
Vehicle Use

Personal Business

Commute to work

Y N

Distance one way

 (KM)

Annual Mileage:

 (KM)

Number of tickets in the
past 3 years?
Number of at fault accidents or claims in the past 6 years?
Has your driver’s license ever been suspended, cancelled, or lapsed?

Y N

Coverage’s required: Collision:

Y N

Comprehensive:

Y N

For RV:
Yr. / Model / Length / Value:
For Motorcycle:
Yr. / Model / #CC's / Value:

HOME / TENANTS / FARM
Coverage:
Home & Contents / Contents Only (Tenant)
Yr. Built / Style / Sq. Ft.:
Interior finishing:
standard / upgraded / superior
Exterior: vinyl siding / stucco
Roof: asphalt shingle / other:
Basement finish:
fully / partial / unfinished
Full Baths:
Bathrooms: #Full / #Half
Heating: Gas Furnace / other:
Garage: attached / detached size:
Deck:

Y N

Size :

Value of all Farm Machinery: $

Farm Outbuildings:$

#Acres:

Any claims in past 5 years?

Y N


COMMERCIAL
Business Name / Type
Type of Building / Location
Yr. Built / Sq. ft.
/ Exterior & Roof Material
Target Premium: $
Deductible Required: $

 

Once we receive the information required, we can begin to process an online quote for you. Thank you for
choosing an online quote from Brown & Ward Insurance!


REQUEST INFORMATION

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Phone *

Email *

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