Homeowners InsuranceQuote Request Form First Name Middle Name(s) Last Name Phone Email Date of Birth Address to be Insured City Province British Columbia Ontario Alberta Postal Code Is this your primary residence? Yes No If it is your primary residence, do you have a rental suite? Yes No If it is not your primary residence, what will its status be? Rented long-term Rented short term (Airbnb, etc.) Vacant Seasonal What is the date you purchased this address? (If less than 5 years) Previous Address Previous City Previous Province Previous Postal Code List any additional owners, and include their date of birth. Have you insured this property before? Yes No If so, please list the insurer, policy number and expiration date. Have you made a claim on this property before? Yes No Please provide a short explanation of your previous claim(s). (If there were no claims, leave this field blank.) How many mortgages are on the property? Please list the mortgage company and amount. Year Built Number of Stories Square Footage Heating Type Electric Furnace Hot Water Oil Fireplace Other Roof Material Roof Asphalt Metal Mix Other Majority Plumbing Material ABS Copper PEX Poly B Other Electrical Material Aluminum Copper Knob and Tube Mix Other Roof Material Roof Asphalt Metal Mix Other Are there water sensors? Yes No Is there a septic tank on t Yes No Is there a sump pump? Yes No Do you have a swimming pool? Yes No Does the property have a basement, and if so, is it finished? Yes - finished Yes - unfinished No What updates, if any have been complete to your home. (Example: new water heater, 2020.) What is the re-build cost of the home? What amount of personal liability would you like? $1 million $2 million $5 million Would you like extra water damage coverage? Yes No Would you like extra earthquake coverage? Yes No Choose Your Deductible Amount $500 $1,000 $1,500 $2,000 $2,5000 $5,000 Please list any scheduled or high-valued items you want added. Do you have any fireplaces? Yes No Do you have a fire alarm, and if so, is it monitored? Yes, and it is monitored Yes, but it is not monitored No fire alarm Do you have a burglary alarm, and if so, is it monitored? Yes, and it is monitored Yes, but it is not monitored No burglary alarm Do you have smoke alarms? Yes No Do you operate a business out of your house? Yes No If, so do you have a business insurance policy? Yes No How many years have you been continuously insured for (on any property)? 0-2 3-4 5-6 7-8 9-10 10+ Is this a non-smoking household? Yes No Do you consent to a soft credit check for a discounted premium? Yes No Optional bicycle damage and competition coverage with a reduced deductible is available. Would you like to learn more? Yes No Do you own any e-bikes? Yes No If Yes, please list the make(s) model and year purchased. How did you hear about Bicycle Broker? ›» SUBMIT