Client Intake Form - MYLIFE Home & Auto Group Ltd.

Step 1 of 23

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

Client Information:

Named Insured

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Marital status

Occupation

Employer

Client Communications:

Address

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

Owned or reside at this address since

MM slash DD slash YYYY

Previous Address

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

Cellular Phone

Alternate Phone

E-mail

To obtain a potential discount on your insurance premium, do you consent to a soft credit check?(Required)

Yes

Do you consent to MYLIFE Home and Auto accessing and sharing your personal information and driving reports with insurers, for the purpose of providing an Auto insurance quote?(Required)

Yes

Add a Second Person?

Yes

Client Information:

Named Insured

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Marital status

Occupation

Employer

Add a Third Person?

Yes

Client Information:

Named Insured

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Marital status

Occupation

Employer

Add a Fourth Person?

Yes

Client Information:

Named Insured

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Marital status

Occupation

Employer

Do you want to add property insurance?

Yes

Which types of property insurance would you like to add?

Homeowner

Tenant

Condominium

Vacation Trailer

Watercraft

Do you want to add auto insurance?

Yes

Driver Information:

First name:

(as it appears on your driver’s licence)

Last name:

(as it appears on your driver’s licence)

Date of birth

MM slash DD slash YYYY

Current driver’s licence:

Age when you got your current driver’s licence:

Upload photo of driver's licence here:

Max. file size: 128 MB.

Is your driver’s licence from outside of Alberta?

Yes

Issue date of driver’s licence outside of Alberta:

MM slash DD slash YYYY

Driving History Documents/Claims Experience Letters

Max. file size: 128 MB.

Current/previous auto insurer:

Start date of first insurance in Alberta:

MM slash DD slash YYYY

Start date of first insurance outside of Alberta:

MM slash DD slash YYYY

Have you had Insurance cancelled for non-payment or refused in the last 5 years:

Yes

How many at-fault accidents have you been involved in in the last 6 years?

How many traffic tickets (not including parking) have you received in the last 3 years:

Would you like to add a second driver?

Yes

Driver Information:

First name:

(as it appears on your driver’s licence)

Last name:

(as it appears on your driver’s licence)

Date of birth

MM slash DD slash YYYY

Current driver’s licence:

Age when you got your current driver’s licence:

Upload photo of driver's licence here:

Max. file size: 128 MB.

Is your driver’s licence from outside of Alberta?

Yes

Issue date of driver’s licence outside of Alberta:

MM slash DD slash YYYY

Driving History Documents/Claims Experience Letters

Max. file size: 128 MB.

Current/previous auto insurer:

Start date of first insurance in Alberta:

MM slash DD slash YYYY

Start date of first insurance outside of Alberta:

MM slash DD slash YYYY

Have you had Insurance cancelled for non-payment or refused in the last 5 years:

Yes

How many at-fault accidents have you been involved in in the last 6 years?

How many traffic tickets (not including parking) have you received in the last 3 years:

Would you like to add a third driver?

Yes

Driver Information:

First name:

(as it appears on your driver’s licence)

Last name:

(as it appears on your driver’s licence)

Date of birth

MM slash DD slash YYYY

Current driver’s licence:

Age when you got your current driver’s licence:

Upload photo of driver's licence here:

Max. file size: 128 MB.

Is your driver’s licence from outside of Alberta?

Yes

Issue date of driver’s licence outside of Alberta:

MM slash DD slash YYYY

Driving History Documents/Claims Experience Letters

Max. file size: 128 MB.

Current/previous auto insurer:

Start date of first insurance in Alberta:

MM slash DD slash YYYY

Start date of first insurance outside of Alberta:

MM slash DD slash YYYY

Have you had Insurance cancelled for non-payment or refused in the last 5 years:

Yes

How many at-fault accidents have you been involved in in the last 6 years?

How many traffic tickets (not including parking) have you received in the last 3 years:

Would you like to add a fourth driver?

Yes

Driver Information:

First name:

(as it appears on your driver’s licence)

Last name:

(as it appears on your driver’s licence)

Date of birth

MM slash DD slash YYYY

Current driver’s licence:

Age when you got your current driver’s licence:

Upload photo of driver's licence here:

Max. file size: 128 MB.

Is your driver’s licence from outside of Alberta?

Yes

Issue date of driver’s licence outside of Alberta:

MM slash DD slash YYYY

Driving History Documents/Claims Experience Letters

Max. file size: 128 MB.

Current/previous auto insurer:

Start date of first insurance in Alberta:

MM slash DD slash YYYY

Start date of first insurance outside of Alberta:

MM slash DD slash YYYY

Have you had Insurance cancelled for non-payment or refused in the last 5 years:

Yes

How many at-fault accidents have you been involved in in the last 6 years?

How many traffic tickets (not including parking) have you received in the last 3 years:

Vehicle Information:

Registered owner:

Vehicle use:

Vehicle type:

Vehicle make/model:

Make Model Year

Vehicle identification (VIN):

Condition when purchased or leased:

Date of purchase or lease:

MM slash DD slash YYYY

Financed or Leased?

Yes

Purchase or lease price:

Interested parties (lienholder or lessor):

First

Company name or additional named insured

Interested party address:

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

How many km do you drive to work or school (one way):

How many km/year:

Winter tires:

Yes

Unrepaired damage:

Yes

Vehicle rebuilt:

Yes

Vehicle modified / accessories:

Yes

Would you like to add a second vehicle?

Yes

Vehicle Information:

Registered owner:

Vehicle use:

Vehicle type:

Vehicle make/model:

Make Model Year

Vehicle identification (VIN):

Condition when purchased or leased:

Date of purchase or lease:

MM slash DD slash YYYY

Financed or Leased?

Yes

Purchase or lease price:

Interested parties (lienholder or lessor):

First

Company name or additional named insured

Interested party address:

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

How many km do you drive to work or school (one way):

How many km/year:

Winter tires:

Yes

Unrepaired damage:

Yes

Vehicle rebuilt:

Yes

Vehicle modified / accessories:

Yes

Would you like to add a third vehicle?

Yes

Vehicle Information:

Registered owner:

Vehicle use:

Vehicle type:

Vehicle make/model:

Make Model Year

Vehicle identification (VIN):

Condition when purchased or leased:

Date of purchase or lease:

MM slash DD slash YYYY

Financed or Leased?

Yes

Purchase or lease price:

Interested parties (lienholder or lessor):

First

Company name or additional named insured

Interested party address:

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

How many km do you drive to work or school (one way):

How many km/year:

Winter tires:

Yes

Unrepaired damage:

Yes

Vehicle rebuilt:

Yes

Vehicle modified / accessories:

Yes

Would you like to add a fourth vehicle?

Yes

Vehicle Information:

Registered owner:

Vehicle use:

Vehicle type:

Vehicle make/model:

Make Model Year

Vehicle identification (VIN):

Condition when purchased or leased:

Date of purchase or lease:

MM slash DD slash YYYY

Financed or Leased?

Yes

Purchase or lease price:

Interested parties (lienholder or lessor):

First

Company name or additional named insured

Interested party address:

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

How many km do you drive to work or school (one way):

How many km/year:

Winter tires:

Yes

Unrepaired damage:

Yes

Vehicle rebuilt:

Yes

Vehicle modified / accessories:

Yes

Insurance Information:

Current insurer or previous:

Start date of first property insurance:

DD slash MM slash YYYY

Current renewal date:

DD slash MM slash YYYY

Expiring premium:

Have you had Insurance cancelled or refused in the last 5 years?

Yes

Have you had any claims in the last 10 years?

Yes

List claims:

Homeowner Property Information:

Use:

Used for Business, Commercial or Farming purposes:

Yes

Risk address:

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

Client has owned/resided at this location since:

MM slash DD slash YYYY

Purchase date:

MM slash DD slash YYYY

Purchase price:

Mortgagee or Line of Credit:

Yes

Interested parties:

First

Company name or additional named insured

Interested party address:

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

Additional named insured or mortgagee or line of credit?

Yes

Second interested party:

First

Company name or additional named insured

Second interested party address:

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

Fire hydrant within 300m:

Yes

Fire hall within 13km:

Yes

Building type:

If other, specify:

Construction type:

If other, specify:

Exterior wall finish:

Occupancy status:

Any unrelated occupants at this location:

Yes

Business operated on the premises:

Yes

Year built:

List any updates/renovations done to home and the year completed:

Electrical wiring (update year):

Primary heat (update year):

Plumbing (update year):

Roofing (update year):

Primary heat type:

If other, specify:

Specify primary heat type:

If other, specify:

Electrical wiring type:

Panel type:

Amperage:

If other, specify:

Roofing type:

If other, specify:

Plumbing type:

If other, specify:

Water heater type:

Year of hot water tank:

Air conditioning:

Yes

Water mitigation:

If other, specify:

Septic system:

Yes

Deck/ patio:

Yes

Pool/ hot tub:

Yes

Central vac system:

Yes

Additional risk information:

Security system protection type:

Total living area in sq feet: (excluding basement)

List appliances:

Level of interior finishings:

Number of bathrooms:

Finished basement:

Garage type:

If other, specify:

Liability requests:

Scheduled items needed:

(List any high value items, jewelry, art, musical instruments)

Note that additional Questionnaires or applications may be required.

Would you like to add a second property?

Yes

Homeowner Property Information:

Use:

Used for Business, Commercial or Farming purposes:

Yes

Risk address:

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

Client has owned/resided at this location since:

MM slash DD slash YYYY

Purchase date:

MM slash DD slash YYYY

Purchase price:

Mortgagee or Line of Credit:

Yes

Interested parties:

First

Company name or additional named insured

Interested party address:

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

Additional named insured or mortgagee or line of credit?

Yes

Second interested party:

First

Company name or additional named insured

Second interested party address:

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

Fire hydrant within 300m:

Yes

Fire hall within 13km:

Yes

Building type:

If other, specify:

Construction type:

If other, specify:

Exterior wall finish:

Occupancy status:

Any unrelated occupants at this location:

Yes

Business operated on the premises:

Yes

Year built:

List any updates/renovations done to home and the year completed:

Electrical wiring (update year):

Primary heat (update year):

Plumbing (update year):

Roofing (update year):

Primary heat type:

If other, specify:

Specify primary heat type:

If other, specify:

Electrical wiring type:

Panel type:

Amperage:

If other, specify:

Roofing type:

If other, specify:

Plumbing type:

If other, specify:

Water heater type:

Year of hot water tank:

Air conditioning:

Yes

Water mitigation:

If other, specify:

Septic system:

Yes

Deck/ patio:

Yes

Pool/ hot tub:

Yes

Central vac system:

Yes

Additional risk information:

Security system protection type:

Total living area in sq feet: (excluding basement)

List appliances:

Level of interior finishings:

Number of bathrooms:

Finished basement:

Garage type:

If other, specify:

Liability requests:

Scheduled items needed:

(List any high value items, jewelry, art, musical instruments)

Note that additional Questionnaires or applications may be required.

Would you like to add a third property?

Yes

Homeowner Property Information:

Use:

Used for Business, Commercial or Farming purposes:

Yes

Risk address:

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

Client has owned/resided at this location since:

MM slash DD slash YYYY

Purchase date:

MM slash DD slash YYYY

Purchase price:

Mortgagee or Line of Credit:

Yes

Interested parties:

First

Company name or additional named insured

Interested party address:

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

Additional named insured or mortgagee or line of credit?

Yes

Second interested party:

First

Company name or additional named insured

Second interested party address:

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

Fire hydrant within 300m:

Yes

Fire hall within 13km:

Yes

Building type:

If other, specify:

Construction type:

If other, specify:

Exterior wall finish:

Occupancy status:

Any unrelated occupants at this location:

Yes

Business operated on the premises:

Yes

Year built:

List any updates/renovations done to home and the year completed:

Electrical wiring (update year):

Primary heat (update year):

Plumbing (update year):

Roofing (update year):

Primary heat type:

If other, specify:

Specify primary heat type:

If other, specify:

Electrical wiring type:

Panel type:

Amperage:

If other, specify:

Roofing type:

If other, specify:

Plumbing type:

If other, specify:

Water heater type:

Year of hot water tank:

Air conditioning:

Yes

Water mitigation:

If other, specify:

Septic system:

Yes

Deck/ patio:

Yes

Pool/ hot tub:

Yes

Central vac system:

Yes

Additional risk information:

Security system protection type:

Total living area in sq feet: (excluding basement)

List appliances:

Level of interior finishings:

Number of bathrooms:

Finished basement:

Garage type:

If other, specify:

Liability requests:

Scheduled items needed:

(List any high value items, jewelry, art, musical instruments)

Note that additional Questionnaires or applications may be required.

Would you like to add a fourth property?

Yes

Homeowner Property Information:

Use:

Used for Business, Commercial or Farming purposes:

Yes

Risk address:

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

Client has owned/resided at this location since:

MM slash DD slash YYYY

Purchase date:

MM slash DD slash YYYY

Purchase price:

Mortgagee or Line of Credit:

Yes

Interested parties:

First

Company name or additional named insured

Interested party address:

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

Additional named insured or mortgagee or line of credit?

Yes

Second interested party:

First

Company name or additional named insured

Second interested party address:

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

Fire hydrant within 300m:

Yes

Fire hall within 13km:

Yes

Building type:

If other, specify:

Construction type:

If other, specify:

Exterior wall finish:

Occupancy status:

Any unrelated occupants at this location:

Yes

Business operated on the premises:

Yes

Year built:

List any updates/renovations done to home and the year completed:

Electrical wiring (update year):

Primary heat (update year):

Plumbing (update year):

Roofing (update year):

Primary heat type:

If other, specify:

Specify primary heat type:

If other, specify:

Electrical wiring type:

Panel type:

Amperage:

If other, specify:

Roofing type:

If other, specify:

Plumbing type:

If other, specify:

Water heater type:

Year of hot water tank:

Air conditioning:

Yes

Water mitigation:

If other, specify:

Septic system:

Yes

Deck/ patio:

Yes

Pool/ hot tub:

Yes

Central vac system:

Yes

Additional risk information:

Security system protection type:

Total living area in sq feet: (excluding basement)

List appliances:

Level of interior finishings:

Number of bathrooms:

Finished basement:

Garage type:

If other, specify:

Liability requests:

Scheduled items needed:

(List any high value items, jewelry, art, musical instruments)

Note that additional Questionnaires or applications may be required.

Tenant Property Information:

Risk address

Street Address Address Line 2 City Province ZIP / Postal Code

If different than mailing address added on the previous form.

Use:

Fire hydrant within 300m:

Yes

Fire hall within 13km:

Yes

Building type:

If other, specify:

Construction type:

If other, specify:

Number of Units in the Building:

Floor level of Unit:

Number of Families:

Any unrelated occupants at this location:

Yes

Business operated on the premises:

Yes

Security system:

Security system protection type:

Value of Personal Contents:

Liability Requests:

Condominium Property Information:

Use:

Risk address

Street Address Address Line 2 City Province ZIP / Postal Code

If different than mailing address added on the previous form.

Purchase date:

MM slash DD slash YYYY

Purchase price:

Mortgagee or Line of Credit:

Yes

Interested parties:

First

Company name or additional named insured

Interested party address:

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

Additional named insured or mortgagee or line of credit?

Yes

Second interested party:

First

Company name or additional named insured

Second interested party address:

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

Fire hydrant within 300m:

Yes

Fire hall within 13km:

Yes

Building type:

If other, specify:

Construction type:

If other, specify:

How many units in the building

Floor level of unit

Number of families:

Occupancy status:

Any unrelated occupants at this location:

Yes

Business operated on the premises:

Yes

Year built:

Primary heat type:

If other, specify:

Water mitigation:

If other, specify:

Security system:

Security system protection type:

Total living area in sq feet: (excluding basement)

Number of bathrooms:

Value of Personal Contents:

Liability requests:

Vacation Trailer Information:

Risk address

Street Address Address Line 2 City Province ZIP / Postal Code

If different than mailing address added on the previous form.

Permanently affixed trailer or permanently affixed trailer with wheels removed/on blocks/skirted:

Yes

Used for business, commercial or farming purposes:

Yes

Home made, kit set or custom built:

Yes

Condition when purchased:

Year of Manufacture:

Manufacturer:

Model:

Serial number:

Length in feet:

Financed or leased:

Yes

Purchase or lease price:

Interested Parties:

Interested party name:

First

Company name

Interested party address

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

Watercraft Information:

Risk address

Street Address Address Line 2 City Province ZIP / Postal Code

If different than mailing address added on the previous form.

Watercraft type:

if other, specify:

Motor Description:

Manufacturer:

Year:

Model:

Serial number:

Type:

Horse-power:

Max speed:

Date purchased:

MM slash DD slash YYYY

Purchase price:

Boat Description:

Manufacturer:

Year:

Model:

Serial number:

Length:

Max speed:

Hull material:

Date purchased:

MM slash DD slash YYYY

Purchase price:

Where is watercraft used / operated:

Is the boat equipped with cooking or heating facilities:

Yes

Is the boat registered or primarily used in the US:

Yes

Was a marine survey completed within the last 3 years:

Yes

Will the boat be used for pleasure use only:

Yes

Safety Course Credit:

Yes

Photos Received:

Yes

Trailer Description:

Manufacturer:

Year:

Model:

Serial number:

Date purchased:

MM slash DD slash YYYY

Purchase price:

Operator Information:

Name:

First Last

Date of birth:

MM slash DD slash YYYY

Years of boating experience:

Boat licence number:

Have you had any boat losses:

Boating courses taken:

Drivers licence number:

Have you had any driving convictions:

Yes

How many driving convictions:

Liability requests:

Do you want to add another operator?

Yes

Operator Information:

Name:

First Last

Date of birth:

MM slash DD slash YYYY

Years of boating experience:

Boat licence number:

Boating courses taken?

Have you had any boat losses:

Drivers licence number:

Have you had any driving convictions:

Yes

How many driving convictions:

Liability requests:

Do you want to add another operator?

Yes

Financing or Leasing Information:

Financed or leased:

Yes

Interested Parties:

Purchase or lease price:

Interested party name:

First

Company name

Interested party address

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

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