JMHI Insurance Group Auto Quote Request Auto insurance questionnaire for JMHI Insurance Group Step 1 of 4 25% Full Name * RequiredWhat is your legal name? Given Name Family Name Home Address * RequiredWhat is your home address (include unit # if applicable)? Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Cell Phone Number * RequiredWhat is your phone number? Email * RequiredWhat is your email address? Enter Email Confirm Email Date of Birth * RequiredWhat is your date of birth? MM DD YYYY What is your gender * RequiredWhat is your gender?MaleFemaleXPrefer not to sayMarital Status * RequiredAre you married or single? SingleMarriedDivorcedWidowedRetirement statusAre you retired? (May be eligible for retiree discount)YesNoStudent statusAre you a student? (May be eligible for a good student discount)YesNo Questions about your driving record Driver’s license number * RequiredWhat is your driver’s license number? Ontario G1 Licensing DateWhat date did you get Ontario G1 license? MM DD YYYY Ontario G2 Licensing DateWhat date did you get Ontario G2 license? MM DD YYYY Ontario G License DateWhat date did you get Ontario G license? MM DD YYYY Government approved driving training course? * RequiredHave you ever attended a government-approved driving training course?YesNoGovernment approved driving training course date * RequiredIf yes, please fill in the training date. MM DD YYYY First Canadian license dateWhen did you first become licensed in Canada? MM DD YYYY First time insured in OntarioWhen were you first insured in Ontario? MM DD YYYY Are you currently insured in Ontario? * RequiredAre you currently insured in Ontario?YesNoName of your current insurance companyWhat is the name of your current insurance company? How long have you been with your current insurer?How long have you been with your current insurer?When does your current policy expire?When does your current policy expire? MM DD YYYY Has an insurer cancelled your policy? * RequiredHas an insurer cancelled your policy in the last 6 years? YesNoWhat was the reason for cancellation? * RequiredWhat was the reason? Any collisions in the last 6 years? * RequiredDo you have any accidents on your record in the past 6 years?YesNoList collisions * RequiredPlease list all claims whether your fault or not. Ever had a claim denied for fraud? * RequiredHave you ever had a claim denied for fraud or misrepresentation?YesNoSuspended license in the last 6 years? * RequiredHas your license been suspended in the last 6 years?YesNoReason for suspended license?What was the reason for the suspended license?Minor traffic convictions? * RequiredDo you have any minor traffic convictions (tickets) on your driving record(convicted in the last 3 years)?YesNoMajor criminal code convictions? * RequiredDo you have any traffic-related major criminal code convictions (like impaired driving)?YesNo Questions about your vehicleNew or Used at time of purchase or lease? * RequiredWas it new or used when you originally leased or purchased it?NewUsedLeased, financed or own vehicle? * RequiredIs the car leased, financed or owned？LeasedFinancedOwnedDate you purchased or leased the vehicle? * RequiredWhen did you purchase or lease the vehicle? MM DD YYYY Purchase price * RequiredHow much did you purchase your vehicle? In Canadian Dollars.Please enter a number from 0 to 10000000.Vehicle Identification Number - VIN * RequiredVIN number Year, Make, and Model of Vehicle * RequiredWhat is the year, make and model of the vehicle?Winter Tires * RequiredDo you put snow tires on your vehicle during the winter months?YesNoAnti-Theft Device * RequiredDo you have an anti theft device?YesNoAnti-Theft Device detailsPlease provide details about the anti-theft device including manufacturer.Monthly or Annual payment * RequiredWill you be paying monthly or annually? (you may give discounts if you pay annually)MonthlyAnnuallyAddress Where vehicle is parkedWhat is the address where the vehicle will be parked? Example: Mailing address is one location but vehicle is used at school. Same as home address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Questions about your driving habitsUsing for work or school? * RequiredWill you be using the vehicle for driving back and forth to work or school?YesNoBoth work and schoolNumber * RequiredIf so, how far is it one way, in kilometers?Please enter a number less than or equal to 1000.Annual Kilometers * RequiredHow many kilometers do you drive annually?Please enter a number less than or equal to 1000000.Liability Coverage * RequiredWould you like your liability coverage limit to be 1 or 2 Million Dollars.1 Million2 MillionWhat type of coverage would you like? * RequiredPlease choose the type of coverage that best matches your needs.Liability OnlyCollision with CompCollisionComprehensiveAll PerilsCommercial use? * RequiredWill you be using the vehicle for any business or commercial use?YesNoSpecific commercial purpose? * RequiredIf so, what percentage of vehicle use is for business? What is the specific commercial purpose?CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Previous Post Motorcycle Insurance Next Post JMHI Insurance Group Auto Quote Request form – Mandarin
