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Home Insurance

Name:

Address:

City:

Province:

Postal Code (X1Y 2Z3):

Phone Number (123-456-7890):

Email:

Do you own your own home, own a condo unit or rent:

HomeownerCondo OwnerRenter

Estimated replacement value of dwelling: (homeowner only):

Estimated replacement value of personal property:

Policy deductible preferred:

Liability amount requested:

How many years have you consistently had a property policy in force:

Number of claims in the past 10 years:

How many years since last claim (if within 10 years):

Do you smoke:

Do you have a monitored alarm? (fire & burglary):

Hydrant of Fire hall protected (if fire hall, how many km’s from it):

Do you have a mortgage/secured line of credit on the property:

What is your occupation:

Year House was built:

Style of house (1 storey, 2 storey, back split etc):

Square Footage:

Outside walls (brick, vinyl etc.):

Basement (if so % finished):

Type of heat (gas, oil etc):

Age of Furnace:

Roof Updated:

Type of wiring and year last updated:

Plumbing and year last updated:

Fire places or woodstoves:

Fire placesWoodstove

Swimming Pool:

YesNo

How many years since last time you moved:

What is your age? (or oldest age of named insured person):

Was your prior policy canceled for non payment:

Was your policy lapsed for any other reason by the insurance company:

What is the amount of jewelry required to be scheduled:

Which insurance company has your current auto insurance:

Please enter the security code: