Home Insurance Form

Primary Applicant


- Required Fields *

- Personal Information

First Name:*	Date Of Birth:*                           mm / dd / yyyy	Email :
Last Name:*	Do you smoke?          Yes No	Phone:*
Gender:*       Female Male		Cell :

- Spouse Information

Marital Status:*      Common Law Divorced Married Separated Single Widowed	Date Of Birth :                           mm / dd / yyyy	Profession :
Spouse Name :	Does he/she smoke?        Yes No	Employer :

- Current Address

Street Number:*	City:*	Postal Code:*
Street Name:*	Province :  Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon	Duration: Yr(s)   Mth(s)
Street Type :      ACRE ACRES ALLEY AUTOROUTE AVENUE BAY BLVD CENTER CHEMIN CIRCLE CLOSE COTE COURT COVE CRESCENT DALE DRIVE ESTATES EXPRESSWAY FREEWAY GARDEN GATE GLEN GREEN GREENS GROVE HEIGHTS HIGHLANDS HIGHWAY HILL KNOLL LANDING LANE LINE LINK LOOP MALL MANOR MEADOW MEWS MONTEE OVAL PARK PARKWAY PATH PIKE PLACE PLAZA POINT PRIVATE PROMENADE RANG RANGE RIDGE RISE ROAD ROUTE ROW RUE RUN SENTIER SQUARE STREET TERRACE TRAIL VIEW VILLAGE VILLAS WALK WAY	Country :   Canada

- Current Employment

Employer :	Province :       Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon	Phone :
Address :	Postal Code :	Extention :
City :	Country :        Canada

- Present Insurer

Are you currently insured?*    Yes No	Have you been canceled or denied by an insurer?*  Yes No
Company Name :	If the answer is Yes, please explain why :
File Number :
Policy Expiration :                               mm / dd / yyyy

- Insurance Record

How many claims have you made in the past 6 years? 0 1 2 3 4 5 6 7 8 9	Do you have a criminal record?  Yes No
What is the total amount you have claimed in the past 6 years?   $

- Risks

Type of construction :	Heating system :        Electric Gaz Oil    If electric, what type?  Breaker Fuse	Do you have an oil tank? Yes No     Oil tank installation year :  Where is the tank installed? Inside The House Outside The House
Year built :
How many units :	Central heating system? Yes No
How many floors :	Do you have a Air Conditioner?   Yes No	Do you have fireplace? Yes No  Number of fireplace(s) :
Ground floor area :    sq ft	Do you have a finished basement?  Yes No

 

- Property Information

Floor type : %  Wood    % Ceramic                    % Carpet    % Other	Do you have a pool?   Yes No   If yes, is it    Inground Above Ground   Size of pool?    sq ft	Do you have a garage?      Yes No   If yes, for how many cars? Is it attached to house? Yes No    Size of garage :   sq ft
Do you have a patio?       Yes No   If yes, construction type :
Number of bathrooms?

Do you have storage space?  Yes No    If yes, what is the size?          sq ft	Distance from Fire Hydrant :  Km
	Distance from Fire Station :    Km

- Protections

Property (Building) value :  $	Refoulement : $
Furniture and other value :   $	Liability :        $

- Additional Information

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