Home Insurance
Postal Code: (X1Y 2Z3)
Phone Number: (123-456-7890)
Email Address: (xxx@yyyy.zzz)
Do you own your own home,
own a condo unit or rent

Estimated replacement value of dwelling: (homeowner only)
Estimated replacement value of personal property:
(condo & renters only)
Policy deductible preferred:
Liability amount requested:
How many years have you consistently had a property policy in force?*
Number of claims in the past 10 years?*
How many years since last claim (if within 10 years)?*
Do you smoke?*
How many smoke detectors are installed in your home?
Do you have a monitored alarm? (fire & burglary)*
Do you have a mortgage/secured line of credit on the property?*
What type of structure is your home (e.g. detached, semi, duplex)?
How many families live in this dwelling?
How many units in this dwelling?
What is the total living area in square feet?
How many storeys is your home?
What year was your home built (if unknown then approx)?
What is the roof covering (e.g. Asphalt Shingle)?
What is the age of the roof covering?
What type of plumbing is in the dwelling (e.g. copper, galvanized)?
What is the electrical service amperage (e.g. 60amp, 100amp)?
Does the electrical panel have fuses or breakers?
What is the age of the electrical wiring in the home?
What type of heat source is in the home (e.g. forced air, boiler)?
What type of fuel is used for heating (e.g. natural gas, oil, propane)?
What is your occupation?*
How many years since last time you moved?*
What is your age? (or oldest age of named insured person)*
Was your prior policy canceled for non payment?*
Was your policy lapsed for any other reason by the insurance company?*
What is the amount of jewelry required to be scheduled?*
Which insurance company has current your auto insurance?*

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