1. Type of Policy *

a) Home owner (detached) – Owner occupied
b) Home owner(detached) – Rent to Others
c) Home owner(detached) – Seasonal use

2. Applicant’s Name, Date of Birth, Occupation (Age discount may apply) *

Name*

First Last

Date of Birth*

Occupation*

3. Co-Applicant’s (Spouse’s or Partner’s) Name, Date of Birth, Occupation (Age discount may apply)

Name

First Last

Date of Birth

Occupation

Relationship to Applicant

4. Address (Risk Location) and Date moved in *

Street No*

Street Name*

City Name*

Postal Code*

Telephone Number*

E-mail Address*

Enter Email Confirm Email

Moved in on*

5. Past Unreported Claim (Fire, Theft, Water Damage etc) *

None
Yes. If Yes, What happened, When, Where, Damaged amount

6. Past Reported Claim and Details in the past 10 years. *

None
Yes. If Yes, What happened, When, Where, Claimed amount, Status of the claim

7. Previous (Current) Insurance

None. If No, specify the reason why you are looking for one now.
Yes. If Yes, specify Insurer’s name, Policy Number, Expiry Date and Total Year Insured.
Previously cancelled, declined or refused to renew by any insurer. If Yes, Why?

8. Year that Building was built (ex. 2005) *

9. Number of mortgage? *

0, 1, 2 or 3*

10. Building’s Construction *

Frame (wood)
Fire Resistive (concrete or stone)
Other (Please specify below)

11. Primary Heating System (Central furnace- Gas, Oil, Propane, Electric, Gas-Hot water, Heat pump or etc. all details )

12. Auxiliary Heating System (Wood burning stove, wood or gas burning fire place or etc. all details )

13. Living space (furnished area of all levels) *

14. Security in the House

Sprinkler
Local Alarm (Burglar and/or Fire)
Monitored Alarm (Burglar and/or Fire): Contract between you and a security company

15. Amount of insurance required for you home(detached house): Enter current replacement cost – Detailed building information is required for a final/adjusted quote. *

16. Optional coverage

Earthquake
Sewer backup

17. Additional Liability Exposure Information *

Additional Families*

Yes
No

How many?*

Rooms Rented to Others*

Yes
No

How many boarders?*

Incidental Office Use*

Yes
No

How often?*

Business Operations at this Location*

Yes
No

What kind of operation?*

18. Credit Check Consent (Soft Credit Check) *

To collect only my personal credit information including my credit score from consumer reporting agencies, as permitted by law for the purposes identified above. I understand that my consent for the use of credit information remains valid until withdrawn by me in writing. By withdrawing or failing to provide my consent to the use of credit information, I understand that I may not benefit from the best rate available to me.

Consent to soft credit check*

Yes
No

Homeowner Insurance Quote Request Form

Insurance for Every Need

Home Insurance Quote

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