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* Name:		Address
* Phone Number		City/Town:
* Email:		* Postal Code
*Required
Age of Insurer:
Have you ever had insurance cancelled or refused? Yes   No
Do you currently insure your property? Yes   No
Number of years prior insurance:
Expiry date with present Insurer		(dd/mm/yyyy)
Age:		(dd/mm/yyyy)
Property Information	Property #1	Property #2
Property type:	Home Condominium Seasonal Residence Apartment	Home Condominium Seasonal Residence Apartment
Use:	Principal home Cottage (summer only) Cottage (year-round) Rented property Other	Principal home Cottage (summer only) Cottage (year-round) Rented property Other
Do you	Own Rent	Own Rent
Year built:
Style of home:	Bungalow Split level Bi level 2 story	Bungalow Split level Bi level 2 story
Square footage:	Main floor    Total	Main floor    Total
Finished Basement Sq. Ft.
Exterior:	Stucco Vinyl Metal Wood Other	Stucco Vinyl Metal Wood Other
Roof:	Shingles Shakes Tiles Metal	Shingles Shakes Tiles Metal
Attached garage:	Yes No    No of Cars	Yes No    No of Cars
Number of bathrooms:	Full   1 2 3 4 5   Half   1 2 3 4 5	Full   1 2 3 4 5   Half   1 2 3 4 5
Fire places:	1 2 3 4 5	1 2 3 4 5
Decking:	Sq. Ft.  Covered   Yes No	Sq. Ft.   Covered   Yes No
Flooring:	Hardwood 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Carpet 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Laminate 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Tile 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Vinyl 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%	Hardwood 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Carpet 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Laminate 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Tile 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Vinyl 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
If property over 20 years old, which of the following have been replaced?	Furnace Roof Wiring Plumbing	Furnace Roof Wiring Plumbing
Is property equipped with an alarm?	None Burglar only Fire only Fire and Burglar	None Burglar only Fire only Fire and Burglar
If yes, is alarm	Choose Local only Monitored by company	Choose Local only Monitored by company
Are you within 300 m of a hydrant?	Yes   No	Yes   No
Are you within 8 km of a fire hall?	Yes   No	Yes   No
Discount Information:
I am mortgage-free
I am a non-smoker
Multiline "Home & Auto"
Amount of coverage required:
Building:
Contents:
Liability:	$500,000 $1,000,000 $2,000,000	$500,000 $1,000,000 $2,000,000
Deductible:	$250 $500 $1,000 None	$250 $500 $1,000
Recent claims:	Type:	Date: (mm/yyyy)	Location involved:
#1:	N/A Break-in Fire Jewelry lost Jewelry stolen Water damage Other		N/A Property #1 Property #2
#2:	N/A Break-in Fire Jewelry lost Jewelry stolen Water damage Other		N/A Property #1 Property #2
#3:	N/A Break-in Fire Jewelry lost Jewelry stolen Water damage Other		N/A Property #1 Property #2
Comments:
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