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Request for Property Insurance Quote
Ontario Residents Only!
 
Please provide ALL applicable information in order for us to promptly complete your request! 

Applicant

Name:     E-mail:  
Address:    Postal Code:  
City:   Phone:  
Sex Date of Birth
 Current Insurance Company
 Renewal Date
Male Female
DD/MM/YYYY
 
MM/YYYY
Date of Birth and Current Insurance Company will allow us to apply discounts if you qualify

Type of Plan Building Information
Comprehensive
Broad 		Dwelling Type Approx Age Construction Other Occupants
 Homeowners   Tenants/Apartment   Condominium


Apartment / Tenants Section (Skip for Homeowners or Condo)
Contents Coverage Liability Coverage Deductible Other Coverages required Other Coverages required
   
Condominium Section (Skip if Homeowners or Apartment)
Coverage Amount
ie) $50,000, $55,000 etc) 		Liability Coverage Deductible Other Coverage required Other Coverage required
   

What type of Fire Protection do you have in your area

Current insured amount on building

Claims in the last 5 years (explain claims in comment section)

Do you currently carry this type of insurance Yes   No

Do you have a wood burning stove Yes   No

If your home is over 25 years old, have the following been up dated;
     Electrical Yes   No
     Plumbing Yes   No
     Heating Yes   No
     Roofing Yes   No

Do you qualify for NON-SMOKERS discount Yes   No

Do you have a full service central monitored alarm system in your home   Yes   No

Do you have Dead bold locks and a Fire extinguisher Yes No

Would you qualify for a MORTGAGE FREE Discount Yes No

Please feal free to provide any additional information that you feal is necessary in order to serve you better.
If you have any Claims please us this field to describe.