Home & Seasonal Quote Form

Name

Address Line 1

Town / City

Province

Postal Code

Phone Number

Email

Employer

Date of Birth

Do You Have a Mortgage? Do You Have a Mortgage? *YesNo

Have you had an Insurance policy cancelled in the past 3 years? Have you had an Insurance policy cancelled in the past 3 years? *YesNo

Expiry Date of Current Policy

Continuous Years of Insurance

Type of Insurance Required Type of Insurance Required *TenantsHouseCondo

Your Property Was Built In

Are You Within 100 Meters of a Fire Hydrant? Are You Within 100 Meters of a Fire Hydrant? *YesNo

Building Coverage Amount

Out Building Coverage Amount

Limited Liability Required Limited Liability Required *YesNo

Content Coverage Required Content Coverage Required *YesNo

Deductible Required On Policy Deductible Required On Policy *5001000

Primary Source of Heat Primary Source of Heat *ElectricOilWood

If Oil Heat, Enter Oil Tank Age and Location

Sewer Backup Coverage Sewer Backup Coverage *YesNo

If No Previous Insurance Explain Reason

Other Sources of Heat (List all that apply)

Do You Have Home Based Business (Explain)

Any Losses In Past 5 Years? (Explain)