| Personal Information |
| Name: |
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| Email Address: |
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| Home Address: |
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| City: |
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| Province: |
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| Postal Code: |
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Phone Number:
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Current Insurance Company:
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| Your Age: |
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Spouse's Age:
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| Rating Information |
| Do You: |
Own Home Own Condo Or Rent
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| Estimated Replacement Cost of Dwelling (HomeOwners Only): |
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| Estimated Replacement Cost of Contents (Condo or Renters Only) |
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| Policy Deductible Preferred: |
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| Liability Amount Requested: |
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| Any claims in the last 5 years: |
Yes No (If yes, comment)
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| Is there an alarm system in home: |
Yes No (If yes, details)
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| Are you non-smokers: |
Yes No
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| Is there a mortgage on the home: |
Yes No
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| Is Property within 1000 ft of Hydrant: |
Yes No
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| Is Property within 8 KM of a Firehall: |
Yes No
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| Is Property within 13km of a Firehall: |
Yes No
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| Year Home was Built: |
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| **If building is over 25 years old, we require the year of updates on.... |
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Roof:
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Heating:
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Plumbing:
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Electrical Panel:
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Type of Heating in Home:
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| Is there a woodstove in your home? |
Yes No
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| (If Yes, # of cords burned) |
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| If Yes, is it CSA/ULC approved? |
Yes No
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| Other Information |
| Do you insure any Special Items? |
Yes No
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| Do you run a business from your home? |
Yes No
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| Are there other locations to insure? |
Yes No
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For additional comments or questions, please use box below.
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