Start a Quote

We’ll find you the right coverage at the right price. You may qualify for significant discounts when you hold multiple policies with our brokerage.

In order to get the most accurate quote, one of our team members will be in touch with you directly.

First Name

Last Name

Email Address

Phone Number

Street + City

Postal Code

What type of insurance are you looking for? What type of insurance are you looking for? Personal (auto, home, cottage, recreational vehicle, travel) Business

How would you like to be contacted? How would you like to be contacted? Phone Email

Which Roughley location is convenient for you? Which Roughley location is convenient for you? Oshawa Bowmanville

"*" indicates required fields

Your Name*

Email*

Preferred Phone Number*

Your Home Address*

City*

Postal Code

Are you looking for Auto, Home and/or Business? (Check that apply)*

Auto

Home

Tenant

Condo

Motorcycle

Business

Other (Please describe, We'll follow up!)

Life Insurance

Travel Insurance

Hidden

Are you looking for Auto, Home and/or Business? (Check that apply) - dropdown*

Other (Please describe, We'll follow up!)*

Vehicle Specific Questionnaire

Let's get rolling.

Consent to Run Driving Reports

I give permission to run driving reports for the purposes of quoting

Driver's License Number/s

CAA Membership # if applicable

If you already have Auto Insurance, when is your renewal date?

MM slash DD slash YYYY

How many vehicles?*

Vehicle #1

Year, Make and Model*

VIN # (If Known)

This helps us be more accurate with quoting as some vehicles have lots of different configurations. You can leave it blank for quoting, we may ask for it later.

Primary Driver*

Please enter a number from 1 to 10.

Occasional Driver/s (If Any)

Please enter a number from 1 to 10.

Name*

Date of Birth

MM slash DD slash YYYY

Driver's License Number*

Use of the Vehicle*

Pleasure

To Work

Business (Describe Use)

Business Description*

Distance One-Way in KM*

Please enter a number greater than or equal to 1.

Approx KM in a Year*

Please enter a number greater than or equal to 1.

Do you have Winter Tires that you change seasonally?*

Yes

Coverages Requested

$1M Liability

$2M Liability

Collision - $500 Deductible

Collision ( - $1000 Deductible

Comprehensive - $500 Deductible

Comprehensive - $1000 Deductible

All Perils

Additional Accident Benefits

Accident Forgiveness - Claim Protection (If you qualify)

OPCF20 - Rental Car Coverage

OPCF43 - Waiver of Depreciation (On newly acquired vehicles)

Other

Typically we recommend $2M Liability, Collision ($1000 Deductible), Comprehensive ($500 Deductible), OPCF20 (Rental Car Coverage) and Accident Forgiveness

Other Coverage Requested*

Vehicle #2

Year, Make and Model - vehcle 2*

VIN # (If Known) - vehcle 2

This helps us be more accurate with quoting as some vehicles have lots of different configurations. You can leave it blank for quoting, we may ask for it later.

Primary Driver - vehcle 2*

Please enter a number from 1 to 10.

Occasional Driver/s (If Any) - vehcle 2

Please enter a number from 1 to 10.

Name 2*

Date of Birth - 2*

MM slash DD slash YYYY

Driver's License Number - 2*

Use of the Vehicle - vehcle 2*

Pleasure

To Work

Business (Describe Use)

Business Description - vehcle 2*

Distance One-Way in KM - vehcle 2*

Please enter a number greater than or equal to 1.

Approx KM in a Year - vehcle 2*

Please enter a number greater than or equal to 1.

Do you have Winter Tires that you change seasonally? - vehcle 2*

Yes

Coverages Requested - vehcle 2

$1M Liability

$2M Liability

Collision - $500 Deductible

Collision ( - $1000 Deductible

Comprehensive - $500 Deductible

Comprehensive - $1000 Deductible

All Perils

Additional Accident Benefits

Accident Forgiveness - Claim Protection (If you qualify)

OPCF20 - Rental Car Coverage

OPCF43 - Waiver of Depreciation (On newly acquired vehicles)

Other

Typically we recommend $2M Liability, Collision ($1000 Deductible), Comprehensive ($500 Deductible), OPCF20 (Rental Car Coverage) and Accident Forgiveness

Other Coverage Requested - vehcle 2*

3+ Vehicles - Please list Year, Make Model # VIN (if known)*

Hidden

Section Break - Home

CAA Membership # if applicable

Home, Tenant or Condo Specific Questionnaire

Your Date of Birth*

MM slash DD slash YYYY

Current / Previous Insurer

Other Insurer*

Policy #

Renewal/Expiry Date or Closing Date*

MM slash DD slash YYYY

Were you Declined, Cancelled, Refused or Non-Renewed in the last 3 years?

Not that I know of

Yes (Please Describe)

Describe - Were you Declined, Cancelled, Refused or Non-Renewed in the last 3 years*

Have you had any Claims in the last 5 years?

Yes (Please Describe)

Describe - Have you had any Claims in the last 5 years*

What storey do you live on?*

Approximate Year Built*

Please enter a number greater than or equal to 1.

Number of Stories*

How many bedrooms?*

Please enter a number greater than or equal to 1.

Number of bathrooms? Are they 2, 3, or 4 piece?*

Please enter a number greater than or equal to 1.

Exterior Finish*

Describe - Exterior Finish*

Approx. Square Footage of the House or Unit*

Please enter a number greater than or equal to 1.

What is the approx. value of your contents?*

Please enter a number greater than or equal to 1.

Ie. furniture, rugs, jewellry - anything that isn't affixed to the unit that you own

Value of the upgrades? Ie everything above and beyond the "basic unit"*

Please enter a number greater than or equal to 1.

Do you have any of the following?*

Centrally Monitored Burglar or Fire Alarm?

Woodstove/insert?

Primary Heating Type*

When was the heating system last updated? (If Applicable)

Please enter a number greater than or equal to 1.

Electrical Panel Amperage*

When was the electrical panel last updated? (If Applicable)

Please enter a number greater than or equal to 1.

Roof Type*

Describe - Roof Type*

Do you know the age of the roof?*

Please enter a number greater than or equal to 1.

In Year

Do you have a Sump Pump?*

Age of your hot water tank?*

Please enter a number greater than or equal to 0.1.

Nice work! You made it. One last question in this section - Do you have other properties that you're interested in getting a quote for?*

Ie cottage, 2nd residence

Describe - Do you have other properties that you're interested in getting a quote for

Hidden

Section Break - Motorcycle

Motorcycle Specific Questions

If you already have insurance, when is your renewal date?

MM slash DD slash YYYY

M1 License Date

MM slash DD slash YYYY

M2 License Date

MM slash DD slash YYYY

M License Date

MM slash DD slash YYYY

Date since you've held continuous motorcycle insurance

MM slash DD slash YYYY

Have you taken a motorcycle safety course?

Yes

Year, Make and Model of the Bike/s*

Vin #'s (If Known)

Helps be a bit more accurate with quoting

Do you commute to work or school on the bike?*

Yes (Describe distance one way in km)

Describe - you commute to work or school on the bike*

Approx KM you ride in a season*

Please enter a number greater than or equal to 1.

Coverages Requested - vehcle 2

$1M Liability

$2M Liability

Collision - $500 Deductible

Collision ( - $1000 Deductible

Comprehensive - $500 Deductible

Comprehensive - $1000 Deductible

All Perils

Additional Accident Benefits

Accident Forgiveness - Claim Protection (If you qualify)

OPCF20 - Rental Car Coverage

OPCF43 - Waiver of Depreciation (On newly acquired vehicles)

Other

Typically we recommend $2M Liability, Collision ($1000 Deductible), Comprehensive ($500 Deductible), OPCF20 (Rental Car Coverage) and Accident Forgiveness

Vehicle Specific Questionnaire

Let's get rolling.

Driver's License Number/s*

CAA Membership # if applicable

Hidden

Business Questionnaire

Businesses are all unique. I'll get some initial info to look up your business and follow up.

Name of Your Business*

What kind of business? What kinds of operations?*

Hidden

Life Insurance

Name*

Phone*

Email*

Your Date of Birth*

MM slash DD slash YYYY

Gender

Smoker or Non Smoker

Amount of Coverage*

Hidden

Travel Insurance

Name*

Phone*

Email*

Your Date of Birth*

MM slash DD slash YYYY

Gender

Date of Travel*

MM slash DD slash YYYY

Destination*

Oshawa Location

1000 Simcoe Street North
Oshawa, Ontario L1G 4W4
Phone: 905.576.7770
Toll Free: 1.888.558.0883
Fax: 905.576.3610
Email: insure@roughleyinsurance.com

Bowmanville Location

31 King Street West
Bowmanville, Ontario L1C 1R2
Phone: 905.697.4257
Toll Free: 1.888.558.0883
Fax: 289-316-3662
Email: insure@roughleyinsurance.com