Insured Name(s):

Email Address:

Home Address:

Res. Tel: Work: Cell:

D.O.B. of Insured:

Property Information:

Location of Property:

Is property presently insured? YES NO

If YES, name of insurance company?

Has any insurance company ever canceled you for any reason? YES NO

How much is property currently insured for?

Do you have a mortgage? YES NO

If YES, Amount of Mortgage?

Have you had any claims in the past 5 yrs? YES NO

If YES please describe when and what happened:

What year has the home built?

Year to be insured purchased the property?

Number of stories: Square footage of buildings:

Property is: Owner Occupied Rented Out Vacant

Are there any apartments on property? YES NO ....If YES how many:

Total number of families living on property?

Total number of people living on people?

Does anyone that smokes live on property? YES NO

Is home located within 300ft to fire hydrant or within 8km to a fire a hall? YES NO

Structure Type (i.e, detached, semi-detached, bi-level, tri-level, etc.)

Construction Type (i.e, wood frame, brick, other):

Foundation Type (i.e, concrete block, poured concrete, other):

Wall Construction Type (i.e, drywall, panelling, wood):

Roofing Type (i.e, asphalt shingles, metal, cedar shingles):

Year last upgrade was made to roofing?:

Is there a basement or crawl space? YES NO

How finished is basement (i.e, 50%, 75%, 100%)?:

Height of walls to ceiling (i.e, 8ft, 9ft, cathedral)?:

Exterior wall material (i.e, vinyl siding/ log / wood / stucco / brick)?:

Any porches or decks? YES NO .. If YES square footage?

Type and amount of flooring in home:
Carpet % Hardwood % Tile % Vinyl % Other %

Number of bathrooms:

Plumbing Type (i.e, copper, pvc, other):

Year last upgrade was made to plumbing?:

Electrical Type (i.e, 60 amp / 100 amp / 200 amp breaker or fuses):

Year last upgrade was made to electrical?:

Primary Heating Type (i.e, oil, wood, electric):

Year last upgrade was made to heating?:

Is there a fireplace or woodstove on property? YES NO .....If YES how many?

Are they CSA approved: YES NO

Year fireplaces or woodstoves installed?

How many bush cords (4x4x8ft) of wood do you burn per season?

Number of smoke detectors in home? Number of fire extinguishers?

Number of carbon monoxide detectors in home?

List any built in appliances in home (i.e, dishwasher, central vac, AC, washer, dryer, etc..):

Is there a garage on property? YES NO

Type of garage (i.e, attached, detached, carport):

Is the garage heated? YES NO .. If YES how is garage heated:

How many cars fit in garage?

List any other buildings on property (i.e, sheds, saunas, barns, etc..):



Is there a pool on property? YES NO

If YES, type and depth of pool?: (i.e, above or in ground, indoor):

List other specific items and their value you would like insured (i.e, boat, motor, trailer, jewelry):

Other Remarks or Comments:


Contact me with quote by: E-Mail Res. Tel Work Tel Cell Mail

.... NOTE: This will clear ALL information