Home Insurance

Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Have you ever had insurance cancelled
or refused?
Yes     No
If yes, please give reason:
Do you currently insure your property?
Yes     No
Number of years prior insurance:
Expiry date with present Insurer
(dd/mm/yyyy)
What is your date of birth? (dd/mm/yyyy)
 
Property #1 Property #2
Property type:
Use:
Do you
Year built:
If property over 20 years old, which
of the following have been replaced or updated?
Furnace
Roof
Wiring
Plumbing
Furnace
Roof
Wiring
Plumbing
Is property equipped with an alarm?
If yes, is alarm
Are you within 300 m of a hydrant?
Yes     No
Yes     No
Are you within 8 km of a firehall?
Yes     No
Yes     No
   
Any Business Use?
Yes     No
Yes     No
If yes, describe:
   
Heating Type  
   
Primary:
Secondary:
Discount Information  
I am mortgage-free
I am a non-smoker
   
Amount of coverage required  
Building* :
Contents:
Liability:
Deductible:
   
Recent claims:
Type: Date (mm/yyyy) Location involved
#1:
#2:
#3:
Comments:
   
 

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