First Name *

Last Name *

Phone *

Address

City *

Province *

Postal Code *

Type of Residence *
Single family homeCondominiumTown homeDuplexApartment

Residence Use *
PrimarySecondarySeasonalRental Property

Date of Birth *
12345678910111213141516171819202122232425262728293031 / 123456789101112 / 191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014

Is the home jointly owned?
YesNo

What is your occupation?

Co-Owner Information

First Name *

Last Name *

Date of Birth *
12345678910111213141516171819202122232425262728293031 / 123456789101112 / 191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014

Purchase Date
12345678910111213141516171819202122232425262728293031 / 123456789101112 / 1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

Estimated Year Built*
12345678910111213141516171819202122232425262728293031 / 123456789101112 / 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

Type of construction*
Aluminum SidingBrickCement Board SidingLog HomeStuccoVinyl SidingWood SidingBlockOther

Type of roof*
Asphalt ShingleMetalTileWood ShakeOther

Number of stories *

Full Bathroom*
12345

Half Bathroom*
12345

What is the total square footage of your home?

Basement
YesNo

Deadbolt Locks
YesNo

Smoke Detector
YesNo

Fire Extinguisher
YesNo

Monitored Fire Alarm
YesNo

Burglar Alarm
YesNo

Home Located Within 8 kilometres of a responding fire hall?
YesNo

Home Located Within 1000 Feet Of A Fire Hydrant
YesNo

Swimming Pool
YesNo

Home Located Within City Limits
YesNo

Do you currently have home insurance coverage?
YesNo

Who is your insurance currently with?

Have you ever had a policy cancelled by a company in the past five years?
YesNo

When does your policy expire?
12345678910111213141516171819202122232425262728293031 / 123456789101112 / 20182019202020212022202320242025

Coverage Amount

What is your annual premium

Are you currently receiving any discounts
YesNo

Deductible Desired
$500$1000$2500

Amount Of Liability Coverage
$1,000,000$2,000,000

Earthquake Coverage Desired?
YesNo

Number of Homeowner’s Claims(*)
01234

Jewelry And Watches $

Silver$

Guns $

Furs $

Stamp And Coin Collection $

Would you like to see if we can save you more money by bundling any of the following policies?
AutoBoatRV/Trailer

Fine Arts And Breakable Items $

Please give any additional comments you feel appropriate for this quotation.

Current email address(*)

Current Email Address Again(*)