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Name:
Address:
City:
Province:
Postal Code:
Phone number:
Email:
Do you own your own home, own a condo unit or rent:
Homeowner
Condo Owner
Renter
Estimated replacement value of dwelling (homeowner only):
Estimated replacement value of personal property:
Policy deductible preferred:
$1,000
$500
Liability amount requested:
$2,000,000
$1,000,000
How many years have you consistently had a property policy in force:
Number of claims in the past 10 years:
How many years since last claim (if within 10 years):
Do you smoke:
Yes
No
Do you have a monitored alarm? (fire & burglary):
Yes
No
Do you have a mortgage/secured line of credit on the property:
Yes
No
What is your occupation:
How many years since last time you moved:
What is your age? (or oldest age of named insured person):
Was your prior policy canceled for non payment:
Yes
No
Was your policy lapsed for any other reason by the insurance company:
Yes
No
What is the amount of jewelry required to be scheduled:
Which insurance company has your current auto insurance: