Auto Insurance Home Insurance Boat Insurance Business Insurance Life Insurance   Home Insurance Name: Address: City: Province: Postal Code: Phone Number: Email Address: Have you ever had insurance cancelled or refused? Yes     No Do you currently insure your property? Yes     No Number of years prior insurance: When should coverage start? (dd/mm/yyyy) What is your date of birth? (dd/mm/yyyy)   Property #1 Property #2 Property type: Home Condominium Seasonal Residence Apartment Home Condominium Seasoned Residence Apartment Use: Principal home Cottage (summer only) Cottage (year-round) Rented property Other Principal home Cottage (summer only) Cottage (year-round) Rented property Other Do you Own Rent Own Rent Year built: If property over 20 years old, which of the following have been replaced? Furnace Roof Wiring Plumbing Furnace Roof Wiring Plumbing Is property equipped with an alarm? None Burglar only Fire only Fire and Burglar None Burglar only Fire only Fire and Burglar If yes, is alarm Local only Monitored by company Local only Monitored by company Are you within 300 m of a hydrant? Yes     No Yes     No Are you within 13 km of a firehall? Yes     No Yes     No     Discount Information   I am mortgage-free I am a non-smoker     Amount of coverage required   Building: Contents: Liability: $500,000 $1,000,000 $2,000,000 $500,000 $1,000,000 $2,000,000 Deductible: $300 $500 $1,000 $300 $500 $1,000     Recent claims: Type: Date (mm/yyyy) Location involved #1: N/A Break-in Fire Jewellery lost Jewellery lstolen Water damage Other Property #1 Property #2 #2: N/A Break-in Fire Jewellery lost Jewellery lstolen Water damage Other Property #1 Property #2 #3: N/A Break-in Fire Jewellery lost Jewellery lstolen Water damage Other Property #1 Property #2 Comments:       Disclaimer