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TF: 1-800-532-0099

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P: 780-532-7800
TF: 1-800-532-0099

© 2022 Prairie Villa Insurance (A division of Peace Country Insurance Brokers Inc.) All Rights Reserved.

Head Office 9917 – 116 Ave. Grande Prairie, AB T8V 3Y3

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Oil & Gas Insurance

This quote will not be auto-generated. You will be contacted by a broker to collect required information.

Step 1 of 2

50%

Personal Information
Name*
First Last
Company Name*
First
Phone Number*
Email Address*
Street Address*
Address Line 2
City*
Province*
Postal Code*
*How do you want us to contact you?*
- Email
- Phone
Which office location would you prefer to contact you?*
- Grande Prairie
- Spirit River
- Sexsmith

Insurance Information
Would you also like a quote for any other type of insurance?
- Personal Auto
- Home
- Condo
- Mobile Home
- Tenant
- Rental Property
- Recreational Unit
- Travel
- Commercial Auto
- Commercial
- Not at this time
Why are you seeking a quote?*
- Price
- Service
- New in area
- New to province
- Newly licensed
- New homeowner
- New tenant
- New business
Have you ever been cancelled for non-payment*
- Yes
- No
How did you hear about us?*
- Facebook
- The Licence Centre
- Driving by
- Website/Google search
Word of mouth – if yes, who referred you?*
- Yes
- No
Who referred you
CAPTCHA

Home Insurance
Auto Insurance
Farm Insurance
Commercial Insurance
Oil & Gas Insurance

Commercial Insurance

This quote will not be auto-generated. You will be contacted by a broker to collect required information.

Step 1 of 2

50%

Personal Information
Name*
First Last
Company Name*
Company Name
Phone Number*
Email Address*
Street Address*
Address Line 2
City*
Province*
Postal Code*
Please tell us what type of insurance you are looking for i.e. Commercial Liability, Commercial Auto, Commercial Property, or describe what you would like to insure.*
How would you like us to contact you?*
- Email
- Phone
Which office location would you prefer to contact you?*
- Grande Prairie
- Spirit River
- Sexsmith

Insurance Information
Would you also like a quote for any other type of insurance?
- Personal Auto
- Home
- Condo
- Mobile Home
- Tenant
- Rental Property
- Recreational Unit
- Travel
- Commercial Auto
- Commercial
- Not at this time
Why are you seeking a quote?*
- Price
- Service
- New in area
- New to province
- Newly licensed
- New homeowner
- New tenant
- New business
Have you ever been cancelled for non-payment*
- Yes
- No
How did you hear about us?*
- Facebook
- The Licence Centre
- Driving by
- Website/Google search
Word of mouth – if yes, who referred you?*
- Yes
- No
Who referred you
CAPTCHA

Farm Insurance

This quote will not be auto-generated. You will be contacted by a broker to collect required information.

Step 1 of 2

50%

Personal Information
Name*
First Last
Phone Number*
Email Address*
Street Address*
Address Line 2
City*
Province*
Postal Code*
Please provide the best phone number to reach you during business hours.*
Which office location would you prefer to contact you?*
- Grande Prairie
- Spirit River
- Sexsmith

Insurance Information
Would you also like a quote for any other type of insurance?
- Personal Auto
- Home
- Condo
- Mobile Home
- Tenant
- Rental Property
- Recreational Unit
- Travel
- Commercial Auto
- Commercial
- Not at this time
Why are you seeking a quote?*
- Price
- Service
- New in area
- New to province
- Newly licensed
- New homeowner
- New tenant
- New business
Have you ever been cancelled for non-payment*
- Yes
- No
How did you hear about us?*
- Facebook
- The Licence Centre
- Driving by
- Website/Google search
Word of mouth – if yes, who referred you?*
- Yes
- No
Who referred you
CAPTCHA

Auto Insurance

This quote will not be auto-generated. You will be contacted by a broker to collect required information.

Step 1 of 3

33%

Personal Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone Number*
Email Address*
Street Address*
Address Line 2
City*
Province*
Postal Code*
Do you give Credit Consent?*
- Yes
- No
Insurance providers often base quotes on credit ratings and if you are eligible for a payment plan. By giving consent you are allowing our brokers to source the best possible priced premium for you.
Number of years licensed*
Number of years with continuous auto insurance*
Any delivery type driving i.e. Skip the Dishes?*
- Yes
- No
Any traffic tickets in the last 3 years (excluding photo radar)?*
- No
- 1
- 2
- 3
- 4 or more (A broker will contact you for details)
Year*
Please provide type of traffic ticket*
Year*
Please provide type of traffic ticket*
Year*
Please provide type of traffic ticket*
Year*
Please provide type of traffic ticket*
Year*
Please provide type of traffic ticket*
Year*
Please provide type of traffic ticket*
Any "at-fault" auto claim(s)?*
- No
- 1
- 2
- 3 or more (A broker will contact you for details)
Year*
Please provide claim details*
Year*
Please provide claim details*
Year*
Please provide claim details*
Have you been cancelled for non-payment in the past 3 years?*
- Yes
- No
Any additional drivers?*
- Yes
- No
Additional Driver Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Number of years licensed*
Number of years with continuous auto insurance*
Does the additional driver do any delivery type driving i.e. Skip the Dishes?*
- Yes
- No
Has the additional driver had any traffic tickets in the last 3 years (excluding photo radar)?*
- No
- 1
- 2
- 3
- More than 3 (A broker will contact you for details.)
Year*
Please provide type of traffic ticket(s).*
Year*
Please provide type of traffic ticket(s).*
Year*
Please provide type of traffic ticket(s).*
Year*
Please provide type of traffic ticket(s).*
Year*
Please provide type of traffic ticket(s).*
Year*
Please provide type of traffic ticket(s).*
Has the additional driver had any "at-fault" auto claim(s)?*
- No
- 1
- 2
- 3 or more (A broker will contact you for details)
Year*
Please provide details of claim*
Year*
Please provide details of claim*
Year*
Please provide details of claim*
Any other additional drivers?*
- Yes
- No
Additional Driver Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Number of years licensed*
Number of years with continuous auto insurance*
Does the additional driver do any delivery type driving i.e. Skip the Dishes?*
- Yes
- No
Has the other additional driver had any traffic tickets in the last 3 years (excluding photo radar)?*
- No
- 1
- 2
- 3
- More than 3 (A broker will contact you for details)
Year*
Please provide type of traffic ticket(s)*
Year*
Please provide type of traffic ticket(s)*
Year*
Please provide type of traffic ticket(s)*
Year*
Please provide type of traffic ticket(s)*
Year*
Please provide type of traffic ticket(s)*
Year*
Please provide type of traffic ticket(s)*
Has the other additional driver had any "at-fault" auto claim(s)?*
- No
- 1
- 2
- 3 or more (A broker will contact you for details.)
Year*
Please provide the other additional drivers details of "at-fault" claim(s).
Year*
Please provide the other additional drivers details of "at-fault" claim(s).
Year*
Please provide the other additional drivers details of "at-fault" claim(s).

Vehicle Information
Make and model of vehicle*
Year of vehicle*
Vehicle VIN*
Type of coverage(s)*
- Select All
- Liability
- Collision
- Comprehensive
Do you have a second vehicle?*
- Yes
- No
Make and model of vehicle*
Year of vehicle*
Vehicle VIN*
Type of coverage(s)*
- Select All
- Liability
- Collision
- Comprehensive
Do you have another vehicle?*
- Yes
- No
Make and model of vehicle*
Year of vehicle*
Vehicle VIN*
Type of coverage(s)*
- Select All
- Liability
- Collision
- Comprehensive

Would you like a quote for any other type of insurance?
- Yes
- No
Which type of insurance?
- Personal Auto
- Home
- Condo
- Mobile Home
- Tenant
- Rental Property
- Recreational Unit
- Travel
- Commercial Auto
- Commercial
- Not at this time
Why are you seeking a quote?*
- Price
- Service
- New in area
- New to province
- Newly licensed
- New homeowner
- New tenant
- New business
How did you hear about us?*
- Facebook
- The Licence Centre
- Driving by
- Website/Google search
- Word of mouth
Who referred you
Please provide the best phone number to reach you during business hours.*
Which office location would you prefer to contact you?*
- Grande Prairie
- Spirit River
- Sexsmith
CAPTCHA

Home Insurance

This quote will not be auto-generated. You will be contacted by a broker to collect required information.

Step 1 of 3

33%

Personal Information
Name*
First Last
Are you currently a client of PVI?*
- Yes
- No
Date of Birth*
MM slash DD slash YYYY
Phone Number*
Email Address*
Street Address*
Address Line 2
City*
Province*
Postal Code*
Who is your current property insurance provider?*
How long have you had property insurance?*
Credit Consent*
- Yes
- No
Insurance providers often base quotes and if you are eligible for a payment plan on credit ratings. By giving consent you are allowing our brokers to source the best possible priced premium for you.

Home Information
Hidden
Value of Home*
Is there a mortgage?*
- Yes
- No
Is the home a mobile home?*
- Yes
- No
Length of Mobile Home*
Width of Mobile Home*
Are there any additions or decks built onto the mobile home?*
- Yes
- No
Square footage or width and length of addition or deck*
Are there any farming operations?*
- Yes
- No
Square Footage*
Year Built*
Hidden
Year of Furnace*
Hidden
Year of Hot Water Tank*
Hidden
Year of Roofing and Type of Material*
Hidden
Has the electrical been upgraded?*
- Yes
- No
Hidden
What year?*
Hidden
Has the plumbing been upgraded?*
- Yes
- No
Hidden
What year?*
Is there a wood burning stove or fireplace?
- Yes
- No
Hidden
How many kms to the closest fire hall?*
Have you had any claims in the past six years?*
- Yes
- No
How many claims in the past six years?*
- 1
- 2
- 2+ (A broker will contact you for information)
Date*
MM slash DD slash YYYY
Description of claim*
Date*
MM slash DD slash YYYY
Description of claim*
Date*
MM slash DD slash YYYY
Description of claim*
Have you been cancelled for non-payment in the past 3 years?*
- Yes
- No

Would you like a quote for any other type of insurance?
- Yes
- No
Which type of insurance?
- Personal Auto
- Condo
- Tenant
- Rental Property
- Recreational Unit
- Travel
- Commercial Auto
- Commercial Property
Hidden
Which type of insurance?
- Personal Auto
- Home
- Condo
- Mobile Home
- Tenant
- Rental Property
- Recreational Unit
- Travel
- Commercial Auto
- Commercial
- Not at this time
Why are you seeking a quote?*
- Price
- Service
- New in area
- New to province
- Newly licensed
- New homeowner
- New tenant
- New business
How did you hear about us?*
- Facebook
- The Licence Centre
- Driving by
- Website/Google search
- Word of Mouth
Who referred you
Please provide the best phone number to reach you during business hours.*
Which office location would you prefer to contact you?*
- Grande Prairie
- Spirit River
- Sexsmith
CAPTCHA