General Information Policy Renewal Date
January
February
March
April
May
June
July
August
September
October
November
December
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
Current Insurance Company
Date First Moved Into Home
January
February
March
April
May
June
July
August
September
October
November
December
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
If less than 5 years, please provide previous address
Type Of Residence
House
Apartment
Condo
Limit Of Insurance ($)
Number Of Years Of Consistent Insurance
Number Of Years With Current Broker
Has insurance been refused/cancelled by an insurance company in the past 5 years?
No
Yes
Is there a mortgage on the house?
No
Yes
If yes, who holds your mortgage?
Any claims in the past 5 years?
No
Yes
If yes, please explain
Hydrant within 300m of home?
No
Yes
Is the home within 8 km of a fire hall?
No
Yes
Volunteer or Full time firefighters?
Volunteer
Fulltime
Are there smoke detectors in the house?
No
Yes
Are candles used in the home, other than birthdays?
No
Yes
Does anyone smoke in the home?
No
Yes
Do you have an alarm?
No
Yes
Do you have a flood prevention device?
None
Sump pump
Other
Is there a business in the home?
No
Yes
If yes, what type of business?
Year House Was Built
If any outbuildings, how many?
Describe Outbuildings
Heating In Outbuildings?
No
Yes
Heating Heating In Outbuildings?
Electric
Gas
Oil
Year Furnace Was Last Updated
Fireplace?
No
Yes
Fireplace Location
Main
Basement
Both
Woodstove?
No
Yes
Electrical Amps
60
100
200
Circuit Breakers Or Fuses
Circuit Breakers
Fuses
Year last updated?
Wiring Type Of Wiring
Copper
Aluminum
Knob & Tube
Year last updated?
Plumbing Type Of Plumbing
Copper
Plastic
Galvanized
Mix
Year last updated?
Roof Type Of Shingles
Year last updated?
Interior Number Of Storeys
Total Living Area Square Footage
Basement?
No
Yes
Primary Interior Flooring
Hardwood
Vinyl
Laminate
Ceramic
Carpet
Primary Interior Covering
Wood
Panneling
Drywall
Primary Exterior Covering
Wood
Stucco
Vinyl
Brick
Stone
How many full baths?
How many half baths?
If you have a hot tub, how many persons?
If you have a sunroom, how many square feet?
If you have a porch, how many square feet?
If you have a deck, how many square feet?
Central Air Conditioning?
No
Yes
Is there a pool?
No
Yes
Pool Surface Area
Attached Garage?
No
Yes
Coverage Deductible
500
1000
$50 lower glass deductible?
No
Yes
Would you like sewer backup insurance?
No
5000
15000
25000
Do you have any scheduled articles (ie. Jewelry, furs, art, etc.) currently listing on your policy or that you would like added to this quote? Please describe item(s) and value.
Do you have any watercraft that require coverage? Please provide details and value.
Do you have a cottage?
No
Yes
