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London East

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Category: South West Ontario

Language(s)	Arabic (درجة) , Bengali (বাংলা) , English , Gujarati ( ગુજરાતી) , Hindi (हिन्दी) , Malayalam (മലയാളം) , Marathi (मराठी) , Punjabi (ਪੰਜਾਬੀ) , Tamil (தமிழ்) , Tibetan (བོད་སྐད།)

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Auto

"*" indicates required fields

Step 1 of 5

20%

GENERAL INFORMATION

Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Phone*

Email*

POLICY INFORMATION

Currently Insured*

Yes

Renewal Date or Date Last Insured*

MM slash DD slash YYYY

How many years continuously insured?*

Was your last policy cancelled by the insurance company?*

Yes

Was your last policy cancelled due to non-payment?*

Yes

How many cancellations due to non-payment in the past 3 years:*

VEHICLE INFORMATION

Year*

Make*

Model*

VIN Number*

Body Type:

Number of Doors:*

Number of Cylinders:*

Drivetrain:*

FWD

RWD

AWD

4WD

Body Style: (regular, convertible, supercab, extended cab, etc.)*

Do you install winter tires on this vehicle?*

Yes

Is your vehicle branded as rebuilt?*

Yes

Do you use your vehicle for business, carry tools related to your business, or have a business logo or advertising on your vehicle?*

Yes

Do you have a second vehicle?*

Yes

Do you use your vehicle for ridesharing or food delivery?*

Yes

Is your vehicle registered to someone other than yourself?*

Yes

VEHICLE #2 INFORMATION

Year*

Make*

Model*

VIN Number*

Body Type:

Number of Doors:*

Number of Cylinders:*

Drivetrain:*

FWD

RWD

AWD

4WD

Body Style: (regular, convertible, supercab, extended cab, etc.)*

Is your vehicle branded as rebuilt?*

Yes

Do you install winter tires on this vehicle?*

Yes

Do you use your vehicle for business, carry tools related to your business, or have a business logo or advertising on your vehicle?*

Yes

Do you use your vehicle for ridesharing or food delivery?*

Yes

Do you have a third vehicle?*

Yes

Is your vehicle registered to someone other than yourself?*

Yes

VEHICLE #3 INFORMATION

Year*

Make*

Model*

VIN Number*

Body Type:

Number of Doors:*

Number of Cylinders:*

Drivetrain:*

FWD

RWD

AWD

4WD

Body Style: (regular, convertible, supercab, extended cab, etc.)*

Is your vehicle branded as rebuilt?*

Yes

Do you install winter tires on this vehicle?*

Yes

Do you use your vehicle for business, carry tools related to your business, or have a business logo or advertising on your vehicle?*

Yes

Do you use your vehicle for ridesharing or food delivery?*

Yes

Is your vehicle registered to someone other than yourself?*

Yes

COVERAGE

Liability Limit*

Please Select One:

Collision Deductible*

Please Select One:

Comprehensive Deductible*

Please Select One:

Loss of Use*

Yes

Limited Waiver of Depreciation*

Yes

Legal Liability for Non-Owned Automobiles*

Yes

Accident Waiver Protection*

Yes

DRIVER #1 INFORMATION:

Sex*

Male

Female

Prefer Not to Answer

Date of Birth*

YYYY

Marital Status*

Single

Married

Separated

Divorced

Widowed

Drivers License No.

License Expiry Date

Year

Month

Day

License Dates:

All fields below are required. If not applicable, please indicate N/A.

G (yyyy/mm)

G2 (yyyy/mm)

G1 (yyyy/mm)

Approved Driver's Training*

Yes

Commute to Work or School*

Yes

If yes, Distance One Way (in km's)*

Annual kilometers driven*

Business Use*

Yes

Annual Km's Driven*

Any Traffic Violations in the past 3 years?*

Yes

If yes, provide dates and details of each conviction in the box below:

Any Accidents/Claims in the past 10 years?*

Yes

If yes, provide dates and details of each accident claim in the box below:

Any license suspensions in the past 6 years?*

Yes

If yes, provide details why your license was suspended, date of suspension and date of reinstatement:

Drives which vehicle:*

Vehicle #1

Vehicle #2

Vehicle #3

Percentage of Use*

Add Second Driver?*

Yes

DRIVER #2 INFORMATION

Sex*

Male

Female

Prefer Not to Answer

Date of Birth*

YYYY

Marital Status*

Single

Married

Separated

Divorced

Widowed

Drivers License No.

License Expiry Date

Year

Month

Day

License Dates:

All fields below are required. If not applicable, please indicate N/A.

G (yyyy/mm)

G2 (yyyy/mm)

G1 (yyyy/mm)

Approved Driver's Training*

Yes

Commute to Work or School*

Yes

If yes, Distance One Way (in km's)

Annual kilometers driven

Business Use*

Yes

Annual Km's Driven

Any Traffic Violations in the past 3 years?*

Yes

If yes, provide dates and details of each conviction in the box below:

Any Accidents/Claims in the past 10 years?*

Yes

If yes, provide dates and details of each accident claim in the box below:

Any license suspensions in the past 6 years?*

Yes

If yes, provide details why your license was suspended, date of suspension and date of reinstatement:

Drives which vehicle:*

Vehicle #1

Vehicle #2

Vehicle #3

Percentage of Use*

Add Third Driver?*

Yes

DRIVER #3 INFORMATION

Sex*

Male

Female

Prefer Not to Answer

Date of Birth*

Month

Day

Year

Marital Status*

Single

Married

Separated

Divorced

Widowed

Drivers License No.

License Expiry Date

Year

Month

Day

License Dates:

All fields below are required. If not applicable, please indicate N/A.

G (yyyy/mm)

G2 (yyyy/mm)

G1 (yyyy/mm)

Approved Driver's Training*

Yes

Commute to Work or School*

Yes

If yes, Distance One Way (in km's)

Annual kilometers driven

Business Use*

Yes

Annual Km's Driven

Any Traffic Violations in the past 3 years?*

Yes

If yes, provide dates and details of each conviction in the box below:

Any Accidents/Claims in the past 10 years?*

Yes

If yes, provide dates and details of each accident claim in the box below:

Any license suspensions in the past 6 years?*

Yes

If yes, provide details why your license was suspended, date of suspension and date of reinstatement:

Drives which vehicle:*

Vehicle #1

Vehicle #2

Vehicle #3

Percentage of Use*

FINAL DETAILS

Any other drivers in the household:*

Yes

If yes, do they have their own vehicle and insurance:

Yes

Do you currently have property insurance (home/condo/apartment) with the same company that insures your automobile(s):*

Yes

This field is for validation purposes and should be left unchanged.

Home

"*" indicates required fields

Step 1 of 4

25%

GENERAL INFORMATION

Name*

Prefix First Last

Daytime Phone*

Email*

Property Location

Address*

Street Address Address Line 2 City Province Postal Code

POLICY INFORMATION

Type of Policy*

Home

Condo

Tenant

Currently Insured*

Yes

Renewal Date or Date Last Insured*

MM slash DD slash YYYY

How many years consecutively insured:*

Was your last policy cancelled by the insurance company?*

Yes

If yes, please provide details:

Was your last policy cancelled due to non-payment?*

Yes

How many cancellations due to non-payment in the past 3 years?

Coverage:

Liability:*

$1,000,000

$2,000,000

Deductible:*

$500

$1000

Sewer Backup Coverage Required?*

Yes

Claims

Did you make any insurance claims within the past 5 years?*

Yes

List all claims in the past 5 years:*

Date

Type

POLICY HOLDER INFORMATION

Owner's Date of Birth*

YYYY

Spouse's Date of Birth

YYYY

Is the property owned by 3 or more individuals?*

Yes

Are all residents of the household non-smokers?*

Yes

Monitored Alarm System:*

Yes

Alarm alerts for:

Check all that apply.

Intrusion

Fire

Smoke

CO2

Number of Smoke Detectors*

Dead Bolt Locks on all doors*

Yes

Distance to Nearest Fire Station*

Distance to Closest Fire Hydrant*

HOMEOWNERS

Year Dwelling Built*

Current Dwelling/Building Value (or purchase price if new):*

Mortgage*

Yes

Owner Occupied*

Yes

Occupied Since*

Number of Families*

Number of Units*

Number of Storeys*

Pool*

Yes

If building is older than 20 years, please provide dates (or approx dates) when the following were last updated:

Plumbing

YYYY

Primary Heating

YYYY

Roof

YYYY

Wiring

YYYY

Do you have a mortgage placed with a private lender or non-conventional mortgage company?*

Yes

Do you have any solar panels on your home?*

Yes

Do you have pets in the household?*

Yes

Do you operate any business within the home?*

Yes

Do you rent any portion of your home or land?*

Yes

Will the home be vacant for 30 days or more?*

Yes

Comments

This field is for validation purposes and should be left unchanged.

Life

Step 1 of 3

33%

GENERAL INFORMATION
Name*
Prefix First Last
Email
Daytime Phone*
Sex*
- Male
- Female
- Prefer Not to Answer
Date of Birth*
MM
DD
YYYY
Amount of Insurance*
Please Select One
If Other, please specify amount:
Smoker*
- Yes
- No
If yes, packages smoked per day:
Please Select One
Have you ever been rated for life insurance due to health conditions*
- Yes
- No
If yes, please explain:
In the past 2 years have you had any of the following:*
- Diabetes
- Cancer
- Heart Attack
- N/A
Do you know of any reason why a life insurance policy would not be issued on your life?*
- Yes
- No
If yes, please explain:

Is this a joint policy quotation?*
- Yes
- No
Spousal Information (If Joint Policy)
Sex*
- Male
- Female
- Prefer Not to Answer
Date of Birth*
MM
DD
YYYY
Smoker*
- Yes
- No
If yes, packages smoked per day:
Please Select One
Have you ever been rated for life insurance due to health conditions*
- Yes
- No
If yes, please explain:
In the past 2 years have you had any of the following:*
- Diabetes
- Cancer
- Heart Attack
- N/A
Do you know of any reason why a life insurance policy would not be issued on your life?*
- Yes
- No
If yes, please explain:
Type of Joint Policy*
Please select one

TYPES OF POLICIES
Policy Options:*
Please Select One
- Level Term
- Guaranteed Term to 100
- Universal Life
Level Term Policy
Length of Policy Term:*
Please select one
Guaranteed Term to 100 Policy
Length of Payment:*
Please select one.
Universal Life Policy
Policy Type*
- Adjustable
- Guaranteed
Length of Payment:*
Please select one.
Term Rider Desired?*
- Yes
- No
If yes, amount:*
Please select one.
If Other, please specify amount:*
Length of Policy Term:*
Please select one
This quotation is based on the information you provide. If the quote is satisfactory and a policy is desired, an insurance claims and experience history will be obtained. If information differs from the information stated, policy premium may be affected. Please be accurate.
Email
This field is for validation purposes and should be left unchanged.

Commercial

Step 1 of 7

14%

GENERAL INFORMATION
Business Name*
Contact Name*
Prefix First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Daytime Phone*
Effective Date*
MM slash DD slash YYYY
Current Insurer*
MULTIPLE LOCATIONS

Please submit a new form for each property or business owned.
This is Location:*
of:*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Type*
Please Select One
If other, please specify:*
Form of Business
- Individually Owned
- Corporate
Type of Products and/or Services Sold:*
Manufactures Own Products:*
- Yes
- No
Target Premium
Policy Deductible*
Please Select One

BUILDING

Please complete the following even if leasing.
Value (if owned)
Is all or a portion of this building rented to others*
- Yes
- No
If yes, amount of annual rent collected:
Year Built*
Construction:
Walls*
Please select one
Floor*
Please select one
Roof*
Please select one
Number of Floors*
Basement*
- Yes
- No
Square Footage of Building*
Square Footage you Occupy*
Square Footage Occupied by Others*
ADJACENT OCCUPANCIES

Please state business types/residencies surrounding your location. (i.e. Left Side - Law Firm, Right Side - Variety Store, Front - House, Behind - Alley)
Left Side:*
Front:*
Right Side:*
Behind:*
Distance to Closest Fire Station*
- None
- 1-8km
- 8-25km
- More than 25km
Distance to Closest Fire Hydrant*
- None
- 1-8km
- 8-25km
- More than 25km
Alarm System*
- Monitored
- Local
- None
Alarm Alerts for:*
Select all that apply.
- Intrusion
- Smoke
- Fire
- CO2
Number of Fire Extinguishers:*
Please select one
Serviced Annually*
- Yes
- No
If deep fat frying is done on premises, is an overhead fire suppression in place:
- Yes
- No
If yes, indicate type:
- CO2
- Chemical
Is there a service contract in place:*
- Yes
- No
When were the filters last cleaned?
MM
DD
YYYY
Is the Building Older than 20 years?*
- Yes
- No
Plumbing*
Month
Day
Year
Primary Heating*
Month
Day
Year
Roof*
Month
Day
Year
Wiring*
Month
Day
Year
Indicate type of service for the following:
Plumbing*
- Copper/ABS
- Galvanized Steel
Primary Heating*
- Forced Air Gas
- Radiant (Stream)
- Electric
- Oil
- Propane
Roof*
- Wood
- Steel
- Concrete
- Wood Joist (Peaked)
Wiring*
- 100 amp
- 200 amp
Supplementary Heating*
- Yes
- No
If Yes, Type of Supplementary Heating:*
- Solid Fuel Stove
- Space Heaters
- Electric
Transformer on Premises:*
- Yes
- No
Air Compresser on Premises:*
- Yes
- No
If any of the following are attached to the building please state value:
Sign
Clock
Antennas/Towers
Glass Coverage Required?
- Yes
- No
Linear Footage of Glass:

CONTENTS
Production Equipment (value)*
Total Stock (value)*
Perishable Stock (value)*
Work in Progress (value)*
Tools on Premises (value)*
Leasehold Improvements (value)*
Office Equipment (value)*
Computer and EDP Equipment (value)*
Computer Software (value)*
Property of Others (value)*

CRIME
Is cash kept on premises:
- Yes
- No
Amount (value)*
Overnight (value)*
Daily Deposit Amount*
Safe on Premises:
- Yes
- No
Class and Fire Rating*
Employee Dishonesty Coverage*
Please Select One
Employee Bonding Required*
Please Select One

ADDITIONAL COVERAGES
Water Escape/Sewer Backup:*
- Yes
- No
Flood:*
- Yes
- No
Earthquake:*
- Yes
- No
Exterior Sign(s) (value)*
Transit (value)*
Temp Locations (value)*
Temp Floater (value):*
- Less than $1000
- More than $1000
Actual Value*
Equipment Floater (value):*
- Less than $1000
- More than $1000
Actual Value*
Misc. Equipment
Other:
Please describe and indicate value.

OPERATIONS/LIABILITY
Amount of Liability*
Please Select One
Total Annual Sales (value)*
Liquor Sales (value)*
Sales to U.S. (value)*
Cost of Sales (value)*
Key Person Payroll (value)*
Ordinary Payroll (value)*
Number of Employees*
Years in Business*
Years in this Industry*
Do your employees use their own vehicles on behalf of your business:*
- Yes
- No
Cranes or Hoists on Premises:*
- Yes
- No
If yes, value of highest amount hoisted (value):*
Are you interested in a quote for a Liability Umbrella?*
- Yes
- No
If yes, amount:*
How many vehicles do you own:*
- 1
- 2
- 3
- 4
- 5
- 5+

INSURANCE HISTORY
Current or Most Recent Insurer*
Policy Renewal Date or Last Date Insured*
Month
Day
Year
Number of Years Consecutively Insured:*
List all claims in the past 5 years:
Claim #1
Month
Day
Year
Claim #1 Type
Claim #1 Amount Paid
Claim #2
Month
Day
Year
Claim #2 Type
Claim #2 Amount Paid
Claim #3
Month
Day
Year
Claim #3 Type
Claim #3 Amount Paid
More than 3 claims?
- Yes
- No
Please list any additional information in the box below:
Comments
This field is for validation purposes and should be left unchanged.

Motorcycle

Step 1 of 3

33%

GENERAL INFORMATION
Name*
Prefix First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day Time Phone*
Email
POLICY INFORMATION
Currently Insured:*
- Yes
- No
Renewal Date or Date Last Insured:*
MM slash DD slash YYYY
How many years continuously insured?*
Was your last policy cancelled by the insurance company?*
- Yes
- No
Was your last policy cancelled due to non-payment?*
- Yes
- No
How many cancellations due to non-payment in the past 3 years:*

VEHICLE INFORMATION
Year*
Make*
Model*
Motorcycle Type*
CC's*
Vin Number*
Purchase Price*
Purchase Date*
Month
Day
Year
Actual Value*
Is it a replica?*
- Yes
- No
Handcrafted/Rebuilt?*
- Yes
- No

COVERAGE
Liability Limit*
Please Select One
Collision Deductible*
Please Select One
Comprehensive Deductible*
Please Select One
DRIVER INFORMATION
Sex*
- Male
- Female
- Prefer Not to Answer
Birth Date*
Month
Day
Year
Marital Status*
Please Select One
Drivers License No.
License Expiry Date

Year
Month
Day
LICENSE DATES:

All fields below are required. If not applicable, please check the N/A field
G (yyyy/mm)
G1 (yyyy/mm)
G2 (yyyy/mm)
M (yyyy/mm)
M1 (yyyy/mm)
M2 (yyyy/mm)
Approved Driver's Training*
- Yes
- No
Commute to Work or School*
- Yes
- No
If yes, Distance One Way (in km's)
Business Use*
- Yes
- No
Annual Km's Driven*
Any Traffic Violations in the past 3 years?
- Yes
- No
If yes, provide dates and details of each conviction in the box below:
Any Accidents/Claims in the past 6 years?
- Yes
- No
If yes, provide dates and details of each accident claim in the box below:
Any license suspensions in the past 6 years?
- Yes
- No
If yes, provide details why your license was suspended, date of suspension and date of reinstatement:
Any other drivers in the household:*
- Yes
- No
If yes, do they have their own vehicle and insurance?
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.

Watercraft

Step 1 of 3

33%

GENERAL INFORMATION
Insured's Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime Phone*
Email
Date of Birth*
Month
Day
Year
Years as a Boat Owner*
Number of Years Experience*
Boating Education and Courses*
Member of Cruising Club*
- Yes
- No
Currently Insured?*
- Yes
- No
Renewal Date or Date Last Renewed*
MM slash DD slash YYYY
How Many Years Continuously Insured*
Has your insurance ever been cancelled or refused?*
- Yes
- No
Was your last policy cancelled due to non-payment?*
- Yes
- No
Driving Record - Have you received any tickets in the last 3 years?*
- Yes
- No
If yes, please provide details:
Previous Insurer:*
Any boating losses in the last 3 years?*
- Yes
- No
If yes, please provide details:

Watercraft/Engine Information
Type of Vessel*
Please Select One
If other, please describe:
Vessel Year*
Vessel Make*
Vessel Model*
Length*
ENGINE INFORMATION
Engine Type*
Please Select One
Number of Engines*
- 1
- 2
- 3
- 4
Total H.P.*
Fuel*
- Gas
- Diesel
Hull Construction*
- Fibreglass
- Wood
- Steel
- Aluminum
Max Speed (km/h)*

POLICY INFORMATION
Market Value*
Trailer Value*
Tender Value*
Other (Examples: Dighy, Equipment & Miscellaneous Items)*
Liability*
- $2,000,000
- $1,000,000
Pleasure Use Only*
- Yes
- No
How Many Operators*
Name
This field is for validation purposes and should be left unchanged.

Travel

Commercial Auto

Step 1 of 3

33%

GENERAL INFORMATION
Company Name*
Name*
Prefix First Last
Email*
Daytime Phone*
Business Type*
Ref by:*
POLICY INFORMATION
Do you have a current commercial auto policy?*
- Yes
- No
Date*
MM slash DD slash YYYY
Name of Current or Most Recent Insurer*
Policy Renewal Date or Date Last Insured*
MM slash DD slash YYYY
Policy cancelled in the last 3 years?
- Yes
- No
If yes, state reason and date:*

VEHICLE #1 INFORMATION
Registered Name for Vehicle*
Type:*
- Personal Name
- Company Name
Year*
Make*
Model*
Body Type*
Please Select One
If Other, Please Specify:*
Date of Vehicle Purchase*
MM
DD
YYYY
VIN #:*
Weight of Vehicle*
- More than 4500kg
- Less than 4500kg
List Price New*
Is Vehicle:*
- Owned
- Leased
Any Business in U.S.?*
- Yes
- No
Percentage of use in U.S.*
Please Describe Main Usage for Vehicle*
Liability Limit*
Please select one
Collision Deductible*
Please Select One
Comprehensive Deductible*
Please Select One
Loss of Use:*
- Yes
- No
Limited Waiver of Depreciation*
- Yes
- No
Legal Liability For Non-Owned Vehicles*
- Yes
- No
List Machinery & Equipment:
Description*
Year Manufactured*
Value*
Description:
Year Manufactured
Value
Description:
Year Manufactured
Value
Haul any trailers?*
- Yes
- No
Use of Trailer
Trailer Type
Trailer Year
Trailer Make
Trailer Model
Trailer Value
Please list the merchandise carried:
Are goods carried for compensation?*
- Yes
- No
If yes, is there a contract in place?*
- Yes
- No
Hauling for others?*
- Never
- Daily
- Weekly
If yes, is there a contract in place?*
- Yes
- No
Radius of Operations:
Normal Radius: Distance one way (kms):*
% of total trips:*
Maximum Radius: Distance one way (kms):*
% of total trips:*
Number of trips per month outside of radius:*
Destinations Travelled to: (Cities, Provinces)*
Garaged Location of Vehicle*
Have second vehicle?
- Yes
- No
VEHICLE #2 INFORMATION
Registered Name for Vehicle*
Type:*
- Personal Name
- Company Name
Year*
Make*
Model*
Body Type*
Please Select One
If Other, Please Specify:*
Date of Vehicle Purchase*
MM
DD
YYYY
VIN #:*
Weight of Vehicle*
- More than 4500kg
- Less than 4500kg
List Price New*
Is Vehicle:*
- Owned
- Leased
Any Business in U.S.?*
- Yes
- No
Percentage of use in U.S.*
Please Describe Main Usage for Vehicle*
Liability Limit*
Please select one
Collision Deductible*
Please Select One
Comprehensive Deductible*
Please Select One
Loss of Use:*
- Yes
- No
Limited Waiver of Depreciation*
- Yes
- No
Legal Liability For Non-Owned Vehicles*
- Yes
- No
List Machinery & Equipment:
Description:*
Year Manufactured*
Value:*
Description:
Year Manufactured
Value:
Description:
Year Manufactured
Value:
Haul any trailers?*
- Yes
- No
Use of Trailer
Trailer Type
Trailer Year
Trailer Make
Trailer Model
Trailer Value
Please list the merchandise carried:
Are goods carried for compensation?*
- Yes
- No
If yes, is there a contract in place?*
- Yes
- No
Hauling for others?*
- Never
- Daily
- Weekly
If yes, is there a contract in place?*
- Yes
- No
Radius of Operations:
Normal Radius: Distance one way (kms):*
% of total trips:*
Maximum Radius: Distance one way (kms):*
% of total trips:*
Number of trips per month outside of radius:*
Destinations Travelled to: (Cities, Provinces)*
Garaged Location of Vehicle*
Have third vehicle?
- Yes
- No
VEHICLE #3 INFORMATION
Registered Name for Vehicle*
Type:*
- Personal Name
- Company Name
Year*
Make*
Model*
Body Type*
Please Select One
If Other, Please Specify:*
Date of Vehicle Purchase*
MM
DD
YYYY
VIN #:*
Weight of Vehicle*
- More than 4500kg
- Less than 4500kg
List Price New*
Is Vehicle:*
- Owned
- Leased
Any Business in U.S.?*
- Yes
- No
Percentage of use in U.S.*
Please Describe Main Usage for Vehicle*
Liability Limit*
Please select one
Collision Deductible*
Please Select One
Comprehensive Deductible*
Please Select One
Loss of Use:*
- Yes
- No
Limited Waiver of Depreciation*
- Yes
- No
Legal Liability For Non-Owned Vehicles*
- Yes
- No
List Machinery & Equipment:
Description:*
Year Manufactured*
Value:*
Description:
Year Manufactured
Value
Description:
Year Manufactured
Value:
Haul any trailers?*
- Yes
- No
Use of Trailer
Trailer Type
Trailer Year
Trailer Make
Trailer Model
Trailer Value
Please list the merchandise carried:
Are goods carried for compensation?*
- Yes
- No
If yes, is there a contract in place?*
- Yes
- No
Hauling for others?*
- Never
- Daily
- Weekly
If yes, is there a contract in place?*
- Yes
- No
Radius of Operations:
Normal Radius: Distance one way (kms):*
% of total trips:*
Maximum Radius: Distance one way (kms):*
% of total trips:*
Number of trips per month outside of radius:*
Destinations Travelled to: (Cities, Provinces)*
Garaged Location of Vehicle*

DRIVER #1 INFORMATION
Name
First Last
Age
Gender
- Male
- Female
- Prefer Not to Answer
Drives Which Vehicle?
Please select all that apply.
- Vehicle #1
- Vehicle #2
- Vehicle #3
Percentage of use of this vehicle:
How long licensed?
Previous Commercial Experience
Please Select One
Number of years experienced driving listed vehicle or similar type of vehicle
Drivers License No.
License Expiry Date

Year
Month
Day
License Dates:

All fields below are required. If not applicable, please indicate N/A.
G (yyyy/mm)
G1 (yyyy/mm)
G2 (yyyy/mm)
A (yyyy/mm)
AZ (yyyy/mm)
Other Class Type & Date (yyyy/mm)
Approved Driver's Training
- Yes
- No
Consecutively insured for:
Please Select One
Minor Convictions in the past 3 years:
- Yes
- No
If yes, provide dates and types:
Major Violations in the past 3 years:
- Yes
- No
If yes, provide dates and types:
Claims in the past 3 years:
- Yes
- No
If yes, provide details on all claims (collision, comprehensive and glass claims):
License Suspension in the past 6 years:
- Yes
- No
If yes, provide details why your license was suspended, date of the suspension and date of reinstatement:
Cancellations for Non-Payment in the past 6 years:
- Yes
- No
If yes, provide details when cancelled and dates:
Add second driver?
- Yes
- No
DRIVER #2 INFORMATION
Name
First Last
Age
Gender
- Male
- Female
- Prefer Not to Answer
Drives Which Vehicle?
Please select all that apply.
- Vehicle #1
- Vehicle #2
- Vehicle #3
Percentage of use of this vehicle:
How long licensed?
Previous Commercial Experience
Please Select One
Number of years experienced driving listed vehicle or similar type of vehicle
Drivers License No.
License Expiry Date

Year
Month
Day
License Dates:

All fields below are required. If not applicable, please indicate N/A.
G (yyyy/mm)
G1 (yyyy/mm)
G2 (yyyy/mm)
A (yyyy/mm)
AZ (yyyy/mm)
Other Class Type & Date (yyyy/mm)
Approved Driver's Training
- Yes
- No
Consecutively insured for:
Please Select One
Minor Convictions in the past 3 years:
- Yes
- No
If yes, provide dates and types:
Major Violations in the past 3 years:
- Yes
- No
If yes, provide dates and types:
Claims in the past 3 years:
- Yes
- No
If yes, provide details on all claims (collision, comprehensive and glass claims):
License Suspension in the past 6 years:
- Yes
- No
If yes, provide details why your license was suspended, date of the suspension and date of reinstatement:
Cancellations for Non-Payment in the past 6 years:
- Yes
- No
If yes, provide details when cancelled and dates:
Add Third Driver?
- Yes
- No
DRIVER #3 INFORMATION
Name
First Last
Age
Gender
- Male
- Female
- Prefer Not to Answer
Drives Which Vehicle?
Please select all that apply.
- Vehicle #1
- Vehicle #2
- Vehicle #3
Percentage of use of this vehicle:
How long licensed?
Previous Commercial Experience
Please Select One
Number of years experienced driving listed vehicle or similar type of vehicle
Drivers License No.
License Expiry Date

Year
Month
Day
License Dates:

All fields below are required. If not applicable, please indicate N/A.
G (yyyy/mm)
G1 (yyyy/mm)
G2 (yyyy/mm)
A (yyyy/mm)
AZ (yyyy/mm)
Other Class Type & Date (yyyy/mm)
Approved Driver's Training
- Yes
- No
Consecutively insured for:
Please Select One
Minor Convictions in the past 3 years:
- Yes
- No
If yes, provide dates and types:
Major Convictions in the past 3 years:
- Yes
- No
If yes, provide dates and types:
Claims in the past 3 years:
- Yes
- No
If yes, provide details on all claims (collision, comprehensive and glass claims):
License Suspension in the past 6 years:
- Yes
- No
If yes, provide details why your license was suspended, date of the suspension and date of reinstatement:
Cancellations for Non-Payment in the past 6 years:
- Yes
- No
If yes, provide details when cancelled and dates:
Additional Comments/Information
Email
This field is for validation purposes and should be left unchanged.

London East

2-1288 Highbury Avenue

London, ON N5Y 1B4

Tel: 226.636.9955

Fax: 1.855.552.7329

Hours of Operation: Mon-Fri 9am-5pm, Sat. by Appt. Only

Main Contact for this Office: Girishkumar Jagdishan

Contact this Location

"*" indicates required fields

Name*

First Last

Email*

Phone

Message*

Comments

This field is for validation purposes and should be left unchanged.

Available Services

Property and Casualty

The products available through our locations are as follows:

Personal Lines

Automobile
Homeowners
Condominium
Tenants
Home Business Insurance
Rental or Income properties
Umbrella Liability Insurance
Marine Insurance
Recreational Vehicles
Classic Automobile
Motorcycle
Snowmobile

Commercial Lines

Packages for Small, Medium and Large Businesses
Industrial & Manufacturing Operations
Non-Profit Organizations
Commercial General Liability
Directors and Officers
Professional Liability/Errors and Omissions
Commercial Umbrella Insurance
US Locations & Liability
Individual & Fleet Rated Commercial Automobile
Farm & Agricultural

Life Insurance and Investments

Life Insurance
Disability Insurance
Critical Illness Coverage
Group/Employee Benefits
Segregated Funds
Estate Planning

Our Team

Girishkumar Jagdishan, MBA

Managing Partner

gjagdishan@all-risks.com
226.636.9955 ext. 19101
226.237.3207

Ginson Syriac

Account Executive

gsyriac@all-risks.com
226.636.9955 ext. 19105

Lall Mann

Account Executive

lmann@all-risks.com
226.636.9955 ext. 19108
416.953.1112

Ruveena Singh

Account Executive

ruveena.singh@all-risks.com
226.636.9955 ext. 19102
365.228.9376

Seema Muralidharan

Account Executive, MTech

smuralidharan@all-risks.com
226.636.9955 ext. 19103

Tom Kochukunnel Baby

Account Executive

tom.kochubaby@all-risks.com
226.636.9955 ext. 19106
226.792.1595

Pasang Sherpa

Account Representative

psherpa@all-risks.com
226.636.9955 ext. 19107

Yuce Zhu

Account Representative

yzhu@all-risks.com
226.636.9955

Monish Girishkumar

Administrative Support

mgirishkumar@all-risks.com
226.636.9955 ext. 19109

Valay Patel

Administrative Support

vpatel@all-risks.com
226.636.9955 ext. 19112

Ademola Adedeji

Account Representative

aadedeji@all-risks.com
226.636.9955

FIND A LOCATION

CLAIMS

FIND A LOCATION

London East

GET A QUOTE

GENERAL INFORMATION

POLICY INFORMATION

VEHICLE INFORMATION

Body Type:

VEHICLE #2 INFORMATION

Body Type:

VEHICLE #3 INFORMATION

Body Type:

COVERAGE

DRIVER #1 INFORMATION:

License Dates:

All fields below are required. If not applicable, please indicate N/A.

DRIVER #2 INFORMATION

License Dates:

All fields below are required. If not applicable, please indicate N/A.

DRIVER #3 INFORMATION

License Dates:

All fields below are required. If not applicable, please indicate N/A.

FINAL DETAILS

GENERAL INFORMATION

Property Location

POLICY INFORMATION

Coverage:

Claims

POLICY HOLDER INFORMATION

HOMEOWNERS

If building is older than 20 years, please provide dates (or approx dates) when the following were last updated:

Step 1 of 3

GENERAL INFORMATION

Spousal Information (If Joint Policy)

TYPES OF POLICIES

Level Term Policy

Guaranteed Term to 100 Policy

Universal Life Policy

This quotation is based on the information you provide. If the quote is satisfactory and a policy is desired, an insurance claims and experience history will be obtained. If information differs from the information stated, policy premium may be affected. Please be accurate.

Step 1 of 7

GENERAL INFORMATION

MULTIPLE LOCATIONS

Please submit a new form for each property or business owned.

BUILDING

Please complete the following even if leasing.

Construction:

ADJACENT OCCUPANCIES

Please state business types/residencies surrounding your location. (i.e. Left Side - Law Firm, Right Side - Variety Store, Front - House, Behind - Alley)

Indicate type of service for the following:

If any of the following are attached to the building please state value:

CONTENTS

CRIME

ADDITIONAL COVERAGES

OPERATIONS/LIABILITY

INSURANCE HISTORY

List all claims in the past 5 years:

Step 1 of 3

GENERAL INFORMATION

POLICY INFORMATION

VEHICLE INFORMATION

COVERAGE

DRIVER INFORMATION

LICENSE DATES:

All fields below are required. If not applicable, please check the N/A field

Step 1 of 3

GENERAL INFORMATION

Watercraft/Engine Information

ENGINE INFORMATION

POLICY INFORMATION

Step 1 of 3

GENERAL INFORMATION

POLICY INFORMATION

VEHICLE #1 INFORMATION

List Machinery & Equipment:

Radius of Operations:

VEHICLE #2 INFORMATION

List Machinery & Equipment:

Radius of Operations:

VEHICLE #3 INFORMATION