Home Owner's Applicaton

Please fill out the following information below

Contact Informaton --------------------------------------------------------------------------------

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?: