Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of birth

MM

DD

YYYY

If you have any alarm systems, please indicate which ones.

Burglar

Fire

Sprinkler

Are the alarm systems monitored?

Yes

No

Do you have a home-based business?

Yes

No

Is this a non-smoking household?

Yes

No

Current policy expiry date

MM

DD

YYYY

Have you had any claims or losses in the past 5 years?

Yes

No

Is earthquake insurance required?

Yes

No

Is the house within 200 metres of a fire hydrant?

Yes

No

Is the house within 8 kilometres of a firehall?

Yes

No

Is there a basement?

Yes

No

If yes, is it finished?

Yes

No

If yes, where is the basement?

Above ground

Below ground

Half and half

If no, is the basement

on a slab

crawlspace

Is there a suite?

Yes

No

Where is the pool located?

In-ground

Above ground

Is there a garage or carport?

Garage

Carport

Both

None

Do you have a swimming pool?

Yes

No

Do you have a hot tub?

Yes

No

What type of roof is it?

Asphalt

Wood

Metal

Clay Tile

Other

Are there breakers or fuses?

Breakers

Fuses

Is it 60, 100 or 200 amp service?

60

100

200

Type of heating - electric or gas furnace?

Electric

Gas Furnace

Do you have your furnace serviced annually?

Yes

No