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Home Insurance
PERSONAL INFORMATION
Name:
Birthdate:
Calendar
Phone 1:
Phone 2:
E-mail:
Current Address:
City:
Province:
AB
BC
MB
NB
NL
NS
NT
NU
On
PE
QC
SK
YT
Postal Code:
Occupation:
Effective date of policy:
Calendar
SPOUSE
Name:
Birthdate:
Calendar
Phone 1:
Phone 2:
Email:
Occupation:
PROPERTY
Address:
City:
Province:
AB
BC
MB
NB
NL
NS
NT
NU
On
PE
QC
SK
YT
Postal Code:
Rebuilding cost:
Year Built:
Square Footage:
Occupancy Date:
Calendar
Number of Stories/Dwelling Style:
Flooring (types and percentage):
Exterior (brick):
Basement completion (percentage):
No. of bathrooms (full/half):
Dwelling Mechanical Systems:
Electrical:
Wiring:
Copper
Aluminum
Knob & Tube
Mix
Unknown
Amps:
Below 60
60
Above 60
100
Over 100
Panel:
Breakers
Fuses
Hot Water tank:
Gas/Electric
Heat Pump
Tankless
Plumbing:
Copper
Copper / ABS
Copper / PVC
Galvanized Steel
Iron
Pex
Poly-B
ABS
Year of Upgrades:
Calendar
Distance to Hydrant or Firehall:
UPGRADES
Roof:
Plumbing:
Fireplace(s):
Deck (sq.ft):
Front Porch (sq.ft):
COVERAGE
Liability limit:
$1,000,000
$2,000,000
Other
Deductible:
$500
$1000
$2000
$2500
$5000
Sewer Backup:
Yes
No
Limit Required $:
Identity Theft:
Yes
No
Limit Required $:
Pool:
None
Above Ground
In Ground
Square Footage:
DISCOUNTS
Mortgage:
Yes
No
Line of Credit:
Yes
No
Smoker:
Yes
No
Previous Claims:
Yes
No
Previous Insurance:
Name of Company & Policy #:
COMMENTS
Alarm:
Local Burglar
Local Fire
Local Buglary and Fire
Monitored Burglar
Monitored Fire
Monitored Buglary and Fire