|
|
| |
| Current
Policy Information |
| Insurance
Company:
|
| Policy
Number:
|
| Policy
Expiry Date:
|
| Amount
of Insurance:
|
| Property
Description |
| Is
the dwelling within 8km (5 miles) of a firehall?
N/A
Yes
No |
| Is
the dwelling within 300m (1000ft.) of a fire hydrant?
N/A
Yes
No |
| Do
you run a business from the premises?
N/A
Yes
No |
| Number
of families in dwelling:
|
| Year
of Construction:
|
| If
built over 15 years ago, indicate the year the following were last
upgraded: |
| Electrical:
|
| Plumbing:
|
| Roofing:
|
| Heating:
|
| Number
of Smoke Detectors:
|
| Number
of Deadbolts:
|
| Is
dwelling equipped with: |
| Centrally
monitored burglar alarm?
N/A
Yes
No |
| Centrally
monitored fire alarm?
N/A
Yes
No |
| Does
the dwelling have an oil tank?
N/A
No
Yes
|
| Age:
Years |
| Do
you have a pet?
N/A
No
Yes
|
|
|
|
|
|
Area of Main Floor:
|
If Other, specify:
If Other, specify:
If Other, specify:
|
Number of Bathrooms:
N/A
2pc
3pc
4pc+
If you have bathrooms with more than 4 pieces please provide details:
(How many pieces?/ How many bathrooms?)
|
|
Number of Fireplaces:
(Inside chimney)
(Outside chimney) |
| Does
the Dwelling include: |
|
Garage?
N/A
No
Yes
|
|
Number of Cars:
|
|
Finished Basement?
N/A
No
Yes Living Space:
|
|
Rec. Room:
|
|
Sunroom?
N/A
No
Yes Area:
|
|
Number of Stories:
|
|
Does the Sunroom have a Basement?
N/A
Yes
No |
|
Deck?
N/A
Yes
No Area:
|
|
Porch (Ground area)? Porch #1
|
|
Area:
|
|
Porch #2
|
|
Area:
|
|
Inground Swimming Pool?
N/A
Yes
No Area:
|
|
If Other, specify:
|
|
Above Ground Swimming Pool?
N/A
Yes
No Area:
|
| Finished
Attic?
N/A
Yes
No |
| Central
Air Conditioning?
N/A
Yes
No |
| Wood
Burning Stove?
N/A
Yes
No |
| Select
Your Specialty Rooms from the following list: |
| Den
(not converted bedroom)
N/A
Yes
No |
| Family
Room (in addition to a Living Room)
N/A
Yes
No |
| Formal
Dining Room (not dining area, dinette or breakfast nook)
N/A
Yes
No |
| Large
Foyer (over 70 sq. ft.)
N/A
Yes
No |
| Laundry
Room (over 70 sq. ft.)
N/A
Yes
No |
|
Library
N/A
Yes
No |
|
Office
N/A
Yes
No |
|
Recreation Room
N/A
Yes
No |
|
Study
N/A
Yes
No |
|
Sunroom
N/A
Yes
No |
|
Other (Specify):
|
| Claims
Information |
|
Have you made any claims in the past five years?
N/A
Yes
No |
|
Description of Claims Amount of Loss
|
| Optional
Coverages |
| Personal
Articles |
|
You may wish to insure the items mentioned below for amounts in
excess of the existing policy limits. Please state the total value
of these items you wish to insure separately. |
Fine Art:
Furs:
Jewellery:
Other:
|
| Secondary/Seasonal
Dwelling |
|
Address:
|
|
Country:
|
|
Lot #:
|
|
Postal Code:
|
|
Is the dwelling within 8km (5 miles) of a firehall?
N/A
Yes
No |
|
Is the dwelling within 300m (1000 ft.) of a fire hydrant?
N/A
Yes
No |
|
Contents value:
|
|
Building Value:
|
|
If over $100,000, please fill in an additional Residential Request
for Quotation and complete the Homeowners sections. |
|
|
|
Please
recheck to make sure you have supplied all information requested.
Please make sure each section in filled, so that all your applicable
discounts can be determined.
|
| |
Enter the text from the image.
|
|
By
submitting this form you agree that the information you provided
above is true and accurate.
|
|
|
|
Important:
Please be accurate in completing this form. Your quotation will
be based on the information you give us today. If these facts
change, your rate will be subject to adjustment.
The Information transmitted is used by this brokerage to develop
a prospect profile, and may or may not be used in the pricing
of any estimated policy premiums.
|
