*First Name

*Last Name

*Email address

*Date Of Birth

*Address

*City

Province

*Region

*Postal Code

*Home Phone

Work Phone

Fax Number

*Preferred contact:

*Policy effective date:

Coverage required:

Current insurance company:

Current policy number:

Current expiry date:

Current dwelling limit:

Current contents limit:

Liability Limit requested:

Current Deductible:

Claims in the last five years:

Type of dwelling:

Area main floor
(square feet):

Number of stories:

Construction type:

Roof covering:

Primary heat:

Auxiliary heat:

Garage - number of cars:

Type of Garage:

Dwelling also includes:

Would you consider your dwelling to be:

Year built:

If your home is over 25 years old, in what year was the following most recently updated:

Electrical

Plumbing

Roofing

Heating

Is the dwelling hydrant protected:

Distance to the nearest fire hall in kilometres:

Number of smoke detectors:

Number of dead bolts:

Is there an alarm system?

Value of personal articles such as jewelry, furs, fine art, bicycles, watercraft, etc:

Describe:

* indicates required fields