Home Insurance

Name:
Date of birth:
Address:
City:
Province:
Postal Code (X1Y 2Z3):
Phone Number (123-456-7890):
Email:
Are you Homeowner, Condo owner or Renter:	HomeownerCondo OwnerRenter
Estimated replacement value of dwelling:
How many years have you consistently had a property policy in force:
Have you ever been non-renewed?:
Any claims in the last 10 years, if yes please provide details:	YesNo
Details:
What is your occupation:
Current Insurance company and renewal date:
Do you give the insurance company consent to check your credit score?:	yesno
Have you ever been cancelled for non-payment in the past 3 years?:	YesNo
Has your policy lapsed for any other reason by insurance company:	YesNo
Is there any jewelry or boat requiring additional coverage:	YesNo
If yes, please provide description and values:
Year house built:
Do you have a mortgage:	yesno
How many years living in current home:
Approximate Age of furnace:
Main source of heat:
If Oil, please provide age of tank:
If oil, please provide location of tank- inside or outside:
Is oil tank metal or fiberglass?:
Is there a wood burning stove/pellet stove?:	YesNo
Is house 1 or 2 story:
Main floor square footage:
What is house constructed of, type of exterior:
What type of roof, when was last update:
Garage details - 1 or 2 car, attached or detached:
How many bathrooms - # of Full and # of half:
% of the basement finished:
Is there a sump pump:	YesNo
Has there ever been a sump pump or water claim:	Yes No
If yes, please provide details (amount, year):
Type of electrical service 60amp/100amp/200amp, breakers or fuses:
When was last update:
Is the plumbing copper, plastic or cast iron:
When was last update:
Is there a pool/pond on the property:	Yes No
If yes, provide details:
Is there a monitored alarm (fire, burglary):	Yes No
Do you have a barn, farm or farm animals:	Yes No
Are there any business operations happening on the property:	Yes No
If yes, provide details:

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