Auto Insurance

Name *

Email address *

Phone number *

Drivers License Number (Optional)

Address

Vehicle year *

Vehicle Make *

Vehicle model *

VIN (Optional)

Ownership *

Please select at least one option.

Own

Finance

Lease

Primary use *

Please select at least one option.

Commute

Pleasure

Business

Rideshare

Annual KM

Parking Overnight

Please select at least one option.

Driveway

Garage

Street

Underground

Date of birth *

Years Licensed *

Please select at least one option.

<1

1

2

3

4

5+

Current Insurer

Policy renewal date (if known)

At-fault accidents in last 6 years? *

Yes

No

Any tickets in the last 5 years? *

If yes how many and when?

Any insurance lapse/cancellation? *

Yes

No

If yes, Brief details

Coverage Preference

Please select at least one option.

Liability only

Standard

Fire & Theft

Full coverage

Deductible Preference

Please select at least one option.

$500

$1000

Not sure

Bundling home & Rental

Yes

No

Best Contact Time

Morning

Afternoon

Evening

Best Contact method

Phone

Sms

Email

Consent to Connect *

Please select at least one option.

I consent to Sharked Group sharing my intake with vetted insurance partners to provide quotes and to be contacted by phone, SMS, or email.

Anything else we should know?