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.