Contact Information

Home Phone:
Office Phone:	Ext.
Fax:
E-mail:

Insurance Information

Have you ever had your insurance cancelled or refused?
	YesNo
Do you currently have insurance?
	YesNo
When would you want the coverage to start? (dd/mm/yyyy)

Property Information

	Location 1	Location 2
Is it a:	Select HouseFreehold TownhouseCondo TownhouseCondo Apt.Rented Apt.	SelectHouseFreehold TownhouseCondo TownhouseCondo Apt.Rented Apt.
Is this your:	Select Principal HomeCottage (year-round)Cottage (Summer Only)Rented PropertyOther	SelectPrincipal HomeCottage (year-round)Cottage (Summer Only)Rented PropertyOther
Do you:	SelectOwn itRent it	SelectOwn itRent it
What year was it built?
If it is over 20 years old, have any of these been updated or replaced:	Furnace	Furnace
	Roof	Roof
	Wiring	Wiring
	Plumbing	Plumbing
Is there an alarm system:	SelectNoneBurglar OnlyFire OnlyBurglar & Fire	SelectNoneBurglar Only Fire OnlyBurglar & Fire
If yes, is it:	SelectLocal OnlyMonitored by company	SelectLocal OnlyMonitored by company
Is your property Located within:	Select300m of Fire Hydrant8 km of Fire HallNeither	Select300m of Fire Hydrant8 km of Fire HallNeither

Coverages & Deductions

Building Amount: ($)
Contents Amount: ($)
Liability Amount:	Select$500,000$1,000,000$2,000,000	Select$500,000$1,000,000$2,000,000
Deductible:	Select$300$500$1,000	Select$300$500$1,000
If you have any extra coverages, such as special coverage for expensive jewellery, boats, furs, etc., please make a note of it in the comments section below.

Claims Information

		Date of Claim
	Type of Claim:	(mm/yyyy)	Location Involved:
1.	SelectNoneBreak-inFireJewelery Lost/StolenWater DamageOther		SelectNoneLocation1Location2
2.	SelectNoneBreak-inFireJewelery Lost/StolenWater DamageOther		SelectNoneLocation1Location2
3.	Select NoneBreak-in FireJewelery Lost/StolenWater DamageOther		SelectNoneLocation1Location2

Comments

Comment
Thank-you for taking the time to fill out this form. Select the "Submit" button below and we will e-mail you a quote by the next business day.   Our quote will include the coverages you selected plus the standard Accident Benefits coverages. We will include the cost of popular optional coverages with our quotation. Optional Accident Benefit coverages can be upgraded by consulting one of our brokers.