First name*

Last name*

Phone Number*

Email*

Address*

City*

Postal Code*

Type of Insurance Required*
HouseTownhouseCondoTenantRented DwellingSeasonal DwellingStrata (Duplex)Seasonal CondoRented CondoMobile HomeContents in Storage

Do You Currently Have a Property Insurance Policy*
YesNo

Any Claims Within the Last Five Years?*
YesNo

Years of Property Insurance Without Interruption*

Any Cancellations or Insurance Refusal Within the Last Five Years?*
YesNoN/A

Year Property Was Built

Square Footage of Residence

Estimated Replacement Value

Construction Type
Masonry - Block or ConcreteFrame - Wood or AluminumUnsureOther

Residence Height (stories, floors)
1 level2 levels3 levels4 levels5 or more levels

Primary Method of Heating
GasOilPropaneWoodElectricHot Water/ SteamCombination FurnaceSolid FuelSolarHeat PumpUnsureOther

Secondary Heating Type
GasOilPropaneWoodElectricHot Water/ SteamCombination FurnaceSolid FuelSolarHeat PumpUnsureOther

Distance to Fire Hydrant
0-100m100-300m300m +Unsure

Distance to Fire Hall
Within 5kmWithin 8kmWithin 15kmOver 15kmUnsure

Any Additional Coverage Required?
YesNoUnsure

Any Additional Coverage For Water Damage?
YesNoUnsure

Any Additional Coverage For Earthquake Damage?
YesNoUnsure

Any Additional Coverage For Sewer Backup?
YesNoUnsure