| If you are unsure of how to complete the form, have a question regarding your coverages or how the claim will be handled, please contact our office during regular business hours. |
| Fields marked with an * are required. |
PERSONAL INFORMATION |
| Name: * |
|
| Email: * |
|
| Phone: * |
ex: ###-###-#### |
| Work: |
ex: ###-###-#### |
|
Fax: |
ex: ###-###-#### |
| Address: * |
|
| City: * |
|
| Province: |
|
| Country: |
|
| Postal Code: * |
ex: A#A #A# |
CURRENT POLICY INFORMATION |
Present Insurance Company:
(NOT the broker name) |
|
| Policy Number:
|
Expiry Date:
|
| How many years have you had condo/apartment insurance? |
YOUR HOME INFORMATION |
| Year home was built: * |
|
Fire Protection (check all that apply)
hydrant within 300m hydrant within 8km unprotected |
| Primary Heat Source |
|
| What is the main floor square footage? * |
|
What type of house is it? *
(i.e. bungalow, 1 1/2 story, split, bi-level) |
|
| Is the quote for a mobile home? * |
Yes
No |
| If you answered 'Yes' to the previous question: |
| What is the size of the trailer? |
|
| Is it CSA approved? |
Yes
No |
| Is it on a foundation or tied down? |
Foundation
Tied Down |
| If it is in the trailer court, provide the name: |
|
| Are there any business operations? * |
Yes
No |
INSURANCE COVERAGES REQUIRED |
| Dwelling Building |
$
|
| Personal Property |
$
|
| Personal Liability |
|
OPTIONAL COVERAGES |
| All house insurance policies contain coverage limitations for valuable items such as jewellery, furs, fine arts, silverware and collectables. You can list these items separately on your policy for an additional premium to ensure full coverage is applied. If you require additional coverage, please provide item details: |
| Value of Items to be Insured |
| Jewellery |
$ |
| Furs |
$ |
| Fine Arts |
$ |
| Silverware |
$ |
| Bikes |
$ |
| Electronics (stereo) |
$ |
| Electronics (computers) |
$ |
| If computer coverage is required, is it used for business? |
Yes
No |
| If computer coverage is required, is it used away from home? |
Yes
No |
| Other |
(Description)
$ |
ADDITIONAL PROPERTY COVERAGES (COTTAGE) |
| Cottage Location |
|
| Cottage Location |
|
| Postal Code |
|
| Year Built |
|
| Dwelling Value |
$ |
| Personal Property |
$ |
DISCOUNTS
(check all of the discounts you may be eligible for) |
| Age (what year were you born): |
|
| Alarm - Burglar - centrally monitored |
Yes
No |
| Alarm - Fire - centrally monitored |
Yes
No |
| Neighborhood Watch (local security program in place) |
|
| Claims Free (no claims in the last 3 years) |
|
| Mortgage Free |
|
| Age of Home (10 years or newer) |
|
CLAIMS HISTORY
Please list all claims against your insurance policy within the past 5 years. |
|
|
| Additional Comments: |
|
How would you prefer to be contacted? *
Email: Home: Work Fax: |
Enter Text Shown in Picture: *
|
Click here to get a new picture if you are
having difficulties reading the image above.
|
| |
|
| Fields marked with an * are required. |
