Name

Address Line 1

Town / City

Province

Postal Code

Phone Number

Email

Employer

Date of Birth

Do You Have a Mortgage? Do You Have a Mortgage?YesNo

Have you had an Insurance policy cancelled in the past 3 years? Have you had an Insurance policy cancelled in the past 3 years?YesNo

Expiry Date of Current Policy

Continuous Years of Insurance

Type of Insurance Required Type of Insurance RequiredTenantsHouseCondo

Your Property Was Built In

Are You Within 100 Meters of a Fire Hydrant? Are You Within 100 Meters of a Fire Hydrant?YesNo

Building Coverage Amount

Out Building Coverage Amount

Limited Liability Required Limited Liability RequiredYesNo

Content Coverage Required Content Coverage RequiredYesNo

Deductible Required On Policy Deductible Required On Policy5001000

Primary Source of Heat Primary Source of HeatElectricOilWood

If Oil Heat, Enter Oil Tank Age and Location

Sewer Backup Coverage Sewer Backup CoverageYesNo

If No Previous Insurance Explain Reason

Other Sources of Heat (List all that apply)

Do You Have Home Based Business (Explain)

Any Losses In Past 5 Years? (Explain)