Last Name:

Address:

City:

Province:

Postal Code:

Email Address:

Home Phone:                   (                    )

Cell Phone:                       (                    )

Fax Phone:                        (                    )

Preferred method of contact:

Insurance Informaton --------------------------------------------------------------------------------

Year Building Built:

Square footage:
Total of all levels excluding basement.

House style:

Number of bathrooms:

Attached garage:

Number of car garage:

Outside wall cover:

Fireplace/Alternate Heat:

Deck:

Deck size:

% of basement completed:

Other distinguishing features (granite countertops or high-end fixtures):

Do you have existing insurance?:

How many claims in the past 5 years:?

If you are in a rural location, how far is the
nearest firehall?:

Do you rent a room or suite?:

Do you have a security system?:

Is is monitored?:

Do you have a monitored fire alarm?:

Date of birth:

If your home is over 15 years old, please indicate the year that upgrading was done on the following:

Roof:(Age of shingles)

Heating system:(Age of furnace)

Wiring:(Age of panel box)

Plumbing:(when were last updates done)

Do you have a home based business?:

Do you have any other property or special
items that require insurance coverage?:

First Name:

Home Owner's Application

Because of the different variables affecting your insurance premiums, we need a few pieces of information from you. To get started on your application, please fill out the following fields below. After you send it, we'll get back to you as timely as possible.

Contact Information --------------------------------------------------------------------------------