HOME OWNERS QUOTE
APPLICATION FORM

 

Name
Address
City
Postal Code -
Phone - -
Fax - -
Email
1.
Dwelling occupancy. ( please check all that apply)
Owner Occupied Rental Roomers Boarders
Sharing with unrelated individuals    
2.
Do you have any rental suites in the house?
Yes No    
If yes, how many suites are rented out?
No. of rented suites    
3.
Fire hydrant within 300 Meters
Yes No    
Fire hall within 8 Km
Yes No    
4.
Year house was built?    
5.
Wood stove / insert on premises?
Yes No    
 
6.
Type of coverage
Basic All Risk Both  
7.
Age Group ( Oldest member on title )
Under 45 45 - 49 50 - 54 55 - 59
60 - 64 65 +    
8.
Do you have a Burglar Alarm?
Yes No    
  If Yes, is it:
  Local Monitored    
 
9.
Do you have a Fire Alarm?
  Yes No    
  If Yes, is it:
  Local Monitored    
 
10.
Have you moved in the last 6 years?
  Yes No    
 
11.
Have you been insured for at least 3 years continuously (not including ICBC)?
  Yes No    
  If yes, how many years have you had habitational insurance?
Indicate # of Years    
 
12.
Have you had any claims in the past (excluding ICBC)?
  3 Years 5 Years 7 Years No
 
13.
Do you have a mortgage on this house?
  Yes No    
 
14.
Is there any business conducted on the premises?
  Yes No    
  If yes, please explain.
 
 
15.
Amount of insurance required for the dewelling?
     
 
16.
Optional Coverages Required:
  Earthquake Yes No Both
  Optional Glass Policy Yes No Both
  Increased Liability 2 Million 3 Million * 5 Million *
  Other (please list what limit required):
 
  * On company's approval
  Responses to all questions required for an accurate quote.
 
     

 

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