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(For our existing policy holders only)
Do you qualify for new or additional discounts? Take a moment to complete our questionnaire and submit it to us. We will review your insurance and advise you shortly thereafter of our results.
Basic information
Name:
Phone number:
Email address:
Auto Discounts
What is your age ?
Please Select
16 years old
17 years old
18 years old
19 years old
20 years old
21 years old
22 years old
23 years old
24 years old
25 years old
26 years old
27 years old
28 years old
29 years old
30 years old
31 years old
32 years old
33 years old
34 years old
35 years old
36 years old
37 years old
38 years old
39 years old
40 years old
41 years old
42 years old
43 years old
44 years old
45 years old
46 years old
47 years old
48 years old
49 years old
50 years old
51 years old
52 years old
53 years old
54 years old
55 years old
56 years old
57 years old
58 years old
59 years old
60 years old
61 years old
62 years old
63 years old
64 years old
65 years old
66 years old
67 years old
68 years old
69 years old
70 years old
71 years old
72 years old
73 years old
74 years old
75 years old
76 years old
77 years old
78 years old
79 years old
80 years old
81 years old
82 years old
83 years old
84 years old
85 years old
86 years old
87 years old
88 years old
89 years old
90 years old
91 years old
92 years old
93 years old
94 years old
95 years old
96 years old
97 years old
98 years old
99 years old
Is your vehicle a HYBRID model ?
Please Select
No
Yes
Have you been insured with the same insurance company for more than 3 consecutive years ?
Please Select
No
Yes
Do you commute less than 8 klm (one way) to work ?
Please Select
No
Yes
How many convictions do you have in the last 3 years ?
Please Select
No conviction
1 convictions
2 convictions
3 convictions
> 3 convictions
When was your most recent "At-Fault" accident ?
Please Select
None
Less than 1 year ago
More than 1 year ago
More than 2 year ago
More than 3 year ago
More than 4 year ago
More than 5 year ago
More than 6 year ago
More than 7 year ago
More than 8 year ago
More than 9 year ago
More than 10 year ago
Is your home or tenants package insured with us ?
Please Select
No
Yes
Are you over 30 years old ?
Please Select
No
Yes
Home Discounts
When was your home built ?
Please Select
Before 1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Are you mortgage free ?
Please Select
Yes
No
Do you have a monitored Fire/Theft alarm ?
Please Select
No
Yes
Is your car(s) insured with us ?
Please Select
No
Yes
Do you have any claims in the last 5 years ?
Please Select
No
Yes
Additional Information
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PRIVACY POLICY