Home Insurance

Name

City/Province

Phone Number

Estimated replacement value of personal property:

How many years have you consistently had a property policy in force:

How many years since last claim (if within 10 years):

Do you have a monitored alarm? (fire & burglary):

Yes

No

What is your occupation?

What is your age? (or oldest age of named insured person):

What is the amount of jewelry required to be scheduled:

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Address

Postal Code

Email

Estimated replacement value of dwelling (homeowner only):

Liability Limit Requested

$1,000,000

$2,000,000

Number of claims in the past 10 years:

Do you smoke?

Yes

No

Do you have a mortgage/secured line of credit on the property:

Yes

No

How many years since last time you moved:

Was your prior policy canceled for non payment:

Yes

No

Was your policy lapsed for any other reason by the insurance company:

Yes

No

Which insurance company has your current auto insurance: