Home Insurance Request Form

First Name *

Last Name *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Date of birth of owner *

Expiry of existing policy or desired effective date: *

Use of the property *

List all owners of the property *

How many years have you carried property insurance? *

Year Built *

Square footage *

Roof type *

What year was the roof updated last? *

Heating type *

What year was the heating system updated last? *

Electrical type *

What year was the electrical system updated last? *

Plumbing Type *

What year was the plumbing system updated last? *

Is there a pool? *YesNo

Is there a wood stove or solid fuel heating? *YesNo

Any business operations at the home? *YesNo

Current reconstruction coverage, if this is a new property to you please indicate your mortgage amount.

Do you consent to a soft credit check? This does not impact your credit score. *YesNo

Do you have a mortgage on the property? *YesNo

Who is the mortgage with (Bank name, branch office address) *

Does the property have an alarm system? *YesNo

Is it monitored? *YesNo

Limit of Liability requested? *

Deductible Requested? *

Condo protection limit *This covers loss assessment, unit improvements, betterments, and contingency coverage.

Condo Protection Deductible *

Contents limit (Up to $150k) *

Would you like Sewer back up coverage? *YesNo

Would you like service line coverage? (This covers repairs for underground wires and pipes from the street to their house) *YesNo

Would you like water protection coverage? *YesNo

Would you like to add any bikes or jewellery? *YesNo

Would you like to add a recreational trailer or boat? *YesNo

Would you like Earthquake coverage? *YesNo

Have you had any claims in the last 5 years? *YesNo

If yes, please provide a description, including dollar amount paid or held in reserve? *

Has the applicant ever been declined or cancelled by an insurance company? *YesNo

Is the home a seasonal, secondary or vacant property? *YesNo

Is the home under construction or will be under construction for more than 5 consecutive months? *YesNo

Are there any farming operations or daycare or business run out of this location? *YesNo

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