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Home Insurance Quote Form
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Home Insurance Quote Form
  Information About You
* First Name:
* Last Name:
* Address:
* Postal Code:   (A9A9A9 format)
* E-mail:
* Phone:   (10 digits only)
* Date of Birth:        
Spouse's Date of Birth:        
  Accurate phone number or email is important if you wish to be contacted
How did you hear about us:
  Your Insurance History
Have you ever had property insurance: Yes     No
If yes, for how many years?   (digits only)
Current insurance expiry date:        
Any claims in the last 5 years? Yes     No
  If you have had any claims, please give us the date and type of loss:
First claim:            
Last claim:            
  Your Other Properties
  For other properties to insure (second home or rental property), please select:
Owned condominium unit:
Owned family dwelling:   (duplex, triplex, Rental, Seasonal, Cottage)
Other than above:
  Your Main Residence
Do you occupy the dwelling? Yes     No
Construction type:
Structure type:
In what year was your home built?
Main residence construction type:
Main residence fire / security system?
What is the main heating system?
Additional heating sources?
Location within 300 mtr. of fire hydrant? Yes     No
Location within 8km of fire station? Yes     No
Commercial unit beside residence? Yes     No
Main residence mortgages?
  Enter the approximate amount it would cost to rebuild your property.
    (excluding the cost of your land)
  About the usage of your main residence
Operate a home based business? Yes     No
  About renovations to your main residence
  Residences older than 25 years rewuire more renovations information:
When was the plumbing updated?
Last electrical system upgrade?
Last time heating system replaced?
When was the roof last replaced?
          Yes     No Do any of the following statements apply to this quote?.
  The home is vacant.
  Three (3) or more families occupy the home.
  The home was built before 1900.
  The home is part of a multi-plex with three (3) or more units.
  You have made three (3) or more property insurance claims in the past five (5) years
  You have three (3) or more mortgages.
* Enter the code as it is shown:

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