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David Castillo Insurance | RIBO Licensed Insurance Broker. Connex Insurance Brokers Ltd.

Personal Info

First Name *

Last Name *

Phone *

Email *

Preferred Contact Method

Email

SMS/Text

Phone

Let us know how you'd like to be contacted

What coverages are you interested in? *

Life Insurance

Business / Commercial Insurance

Auto Insurance

Home Insurance

Check all that apply

Life Insurance

Do you use tobacco or nicotine products?

YES

NO

Desired Coverage Amount:

If you are unsure how much you need, just put "unsure"

Gender

Date of birth

Other Info

Anything else we should know?

Commercial / Business Insurance

Business Name

Type of business

How many years in Business?

What do you need covered?

Auto Insurance

Effective date you require coverage

Commute distance to work/school for each driver (KMs)

Number of days you commute in a week

Does the vehicle(s) have winter tires?

Date of purchase

Amount of purchase

Is the vehicle leased or financed?

Upload Driver's License

Upload Picture of Ownership

VIN no. must be visible

VIN No.

Enter your VIN No.

Home Insurance

Address

Street Address

City

State

Country

Postal Code

Year Built

Building Type (1 Storey, 2 Storey, Bungalow, Backsplit, Sidesplit……)

Construction (Masonry, Brick Veneer, Siding-Vinyl, Siding-Aluminum….)

Foundation (Concrete, Concrete Block, Crawl space…..)

Number of units

Attached Garage? If so, for how many cars?

Finished basement? How Much in %

Total finished square footage?

Is there a sump pump?

Is there a swimming pool?

Where is the washing machine located?

Is electrical wiring copper? If not, what kind is it?

What is the amperage of the electrical?

Is plumbing copper/PVC? If not, what material is it?

Type of heat (Central furnace- gas, Electric baseboards, etc…)?

Is the roof Asphalt Shingles? If not, please specify material.

What year were the following replaced or updated (Type of update)? * Roof * Furnace * Electrical * Plumbing

Number of kitchens

Number of bathrooms

Do you require Earthquake coverage?

Do you have a Mortgage?

If so, how much is the Mortgage for?

Do you smoke?

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Connex Insurance Brokers Ltd.

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