Property Insurance

Name:

Address:

City:

Province:

Postal Code:

Phone Number:

Email Address:

Have you ever had insurance cancelled or refused?

Yes

Do you currently insure your property?

Yes

When should coverage start? (dd/mm/yyyy)

What is your date of birth? (dd/mm/yyyy)

Property #1

Property #2

Property type:

Use:

Do you

Year built:

If property over 20 years old, which of the following have been replaced?

Is property equipped with an alarm?

If yes, is alarm

Proximity to fire services:

Discount Information

I am mortgage-free

I am a non-smoker

Amount of coverage required

Building:

Contents:

Liability:

Deductible:

Recent claims:

Type:

Date (mm/yyyy)

Location involved

#1:

#2:

#3:

Comments:

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