_ Personal Information

First Name:

Last Name:

E-mail Address:

Address:

Apt. Number:

City:

Province: Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal Code:

Home Phone:

Business Phone:

Fax Number:

Notes or Comments:

__Current Policy Information

Insurance Company:

Policy Number:

Policy Expiry Date:

Amount of Insurance:

__Property Description

Is the dwelling within 8 km (5 miles) of a firehall? N/A Yes No

Is the dwelling within 300 m (1,000 ft) of a fire hydrant? N/A Yes No

Do you run a business from the premises? N/A Yes No

Number of families in dwelling:

Year of construction:

If built over 15 years ago, indicate the year the following were last upgraded:

Electrical:

Plumbing:

Roofing:

Heating:

Number of Smoke Detectors:

Number of Deadbolts:

Is dwelling equipped with a centrally monitored burglar alarm? N/A Yes No

Is dwelling equipped with a centrally monitored fire alarm? N/A Yes No

Does dwelling have an oil tank? N/A Yes No

If "YES" where is it located: Above Ground Below Ground Basement ---Age: years

Do you have a pet? N/A Yes No

If "YES" what type of pet: Dog Cat Other

Type of dwelling: Principal Residence Seasonal Residence Rented Dwelling Appartment

Number of Storeys: Bungalow Two-Storey Split-Level 1.5 Storey 2.5 Storey Raised Bungalow

Area of Main Floor: sq ft sq m

Construction Type: Brick Veneer Frame Masonry Other ---

If "OTHER" specify:

Roof Covering: Shingle Tar/Gravel Tile Other --

-If "OTHER" specify:

Primary Heating: Central/Forced Air Gas Central/Forced Air Electric Central/Forced Air Oil Central Hot Water Electric Hot Water Other ---

If "OTHER" specify:

Number of Bathrooms: N/A 2pc 3pc 4pc+

If you have bathrooms with more than 4 pices, please provide details (How many pieces/How many bathrooms?):

Number of Fireplaces: with inside chimney with outside chimney

Does dwelling have a garage? N/A Yes No

If "YES" select the type: Built In Detached Attached Carport Basement ---

and the Construction Type: Frame Masonry Concrete Brick

Does dwelling have a finished basement? N/A Yes No

If "YES" Area of Living Space: sq ft sq m

If "YES" Area of Rec. Room: sq ft sq m

Does dwelling have a sunroom? N/A Yes No

If "YES" Number of Stories:

Does the sunroom have a basement? N/A Yes No

Does dwelling have a deck? N/A Yes No

If "YES" Area of the Deck: sq ft sq m

Does dwelling have a porch?

Porch #1:

---Area: sq ft sq m --- Number of Stories:

---Type: Open Enclosed --- Construction Type: Masonry Wood

Porch #2:

---Area: sq ft sq m ---Number of Stories:

---Type: Open Enclosed ---Construction Type: Masonry Wood

Does dwelling have an inground swimming pool? N/A Yes No

If "YES" Area of the Pool: sq ft sq m

Pool Type: Concrete Fibre Glass Vinyl Liner Other

If "OTHER" specify:

Does dwelling have an above ground swimming pool? N/A Yes No

If "YES" Area of the Pool: sq ft sq m

Does dwelling have a finished attic? N/A Yes No

Does dwelling have central air conditioning? N/A Yes No

Does dwelling have a wood burning stove? N/A Yes No

Select your specialty rooms from the following List:

Den (not converted bedroom): N/A Yes No

Family Room (in addition to a Living Room): N/A Yes No

Formal Dining Room (not dining area, dinette or breakfast nook):
N/A Yes No

Large Foyer (over 70 sq ft): N/A Yes No

Laundry Room (over 70 sq ft): N/A Yes No

Library: N/A Yes No

Office: N/A Yes No

Recreation Room : N/A Yes No

Study: N/A Yes No

Sunroom: N/A Yes No

Other (specify):

__Claims Information

Have you made any claims in the past 5 years? N/A Yes No

Description of claim's amount of loss:

__Optional Coverages

Personal Articles

You may wish to insure the items mentioned below for amounts in excess of the existing policy limits. Please state the total value of these items you wish to insure seperately.

Fine Art $

Furs $

Jewellery $

Other:

Secondary Dwelling

Address:

Country:

Lot #:

Postal Code:

Is the dwelling within 8 km (5 miles) of a firehall? N/A Yes No

Is the dwelling within 300 m (1,000 ft) of a fire hydrant? N/A Yes No

Contents Value: $

Buildi

ng Value: $

If over $100,000, please fill in an additional Residential Insurance Quote form and complete the homeowners section.

Please recheck to make sure you have supplied all information requested.
Please make sure each section is filled, so that all your applicable discounts can be determined.

By submitting this form you agree that the information you are providing is true and accurate

Coverages cannot be bound or changes made through our website or e-mail. You must call our office and speak to a Licenced Insurance Broker.