Please Complete All Field Areas
Contact Information:
Your name:
E-Mail Address:
Home Tel: (###-###-####) Work Tel:
Addr: Line 1 (number & street name)
Line 2 (city, province, postal code)
Your Date of Birth: Any smokers living at home?YesNo
Current Home Insurance Information:
Do you currently own Home insurance? Yes No,
If "No", Have you owned home insurance in the past?Yes No
Present Insurer (example: Economical Mutual)
Renewal Date of Current Insurance
Home Quote Details:
Is this home your Primary Residence? Yes No Do you have a mortgage? Yes No
The style of your home? (ie: 1-Level Ranch, 2-Storey, 3-Storey)
What year was your home built? What is the"Main Floor"square footage?
Outside Finished in Brick? Yes No >>>> If "Yes", Percentage?25% 50% 75% 100%
Outside Finished in Siding? Yes No >>>> If "Yes", Percentage?25% 50% 75% 100%
Is basement finished? Yes No >>>> If "YES", Pecentage Finished? 25% 50% 75% 100%
Do you have a garage? Yes No >>>> If "Yes", Size?1-Car 2-Car 3-Car
Is the Garage attached to the home? Yes No
Any Fireplaces or Woodburning Units? Yes No If "Yes" Are they?Wood Burning Natural Gas Both Type
Number of Bathrooms: 1 Bathroom 1&1/2 Bathroom 2 Bathroom 3 Bathroom 4 Bathroom
Any Skylights? Yes No >>>> If "Yes", How Many?1 2 3 4
Number of Outside Decks: 1 Deck 2 Decks 3 Decks >>> Total square footage of decks:
Is there a swimming pool? Yes No >>>> If "Yes", Is it? In-Ground Above-Ground
Pool Size:
Services & Upgrades:
Heating Type: Last Upgraded? (Year)
If Oil Heat, where is Oil Tank located? Inside Outside Age of Oil Tank
Do you Have Central Air Conditioning? Yes No
Electrical: Electrical Panel? Last Updated? (Year)
Is Plumbing System Copper/ABS Mix? Yes No Last Updated? (Year)
Roof Type: Last Upgraded? (Year)
Claims History:
Please give details of any claims you've made in the
past 5 year period:
Any additional comments?
