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Home Insurance Application

Submission of this information does not represent a binding of any insurance contract or agreement. Additional information may be required in order to get an accurate quote of insurance.

Name
First Last
Phone
Email
Date of Birth

MM-DD-YYYY
Have You Ever Had A Cancalletion for Non-payment, claims or cancelled for Any Other reason?
- Yes
- No
If Cancelled Please Describe, When Cancelled and for what:
Are You A First Time Home Buyer?
- Yes
- No
Have You Ever Had Any Claims?
- Yes
- No
If You Have Had Claims: Please Describe, How Many Claims, The Date, What Occured and How Much The Claim Was For:
Is this A Smoke-Free House Hold?
- Yes
- No
Absolutely no one living in the household smokes
How Many Mortgages Do You or Will You Have On The Property?
How Many Years Have You Had Continuous House Insurance?
How Long Have You Had House Insurance On The Current Property?
How Many Years Have You Had The Property Insured With The Same Insurance Company?
Date Property First Purchased or If New Purchase - The Closing Date

MM-DD-YYYY
Property Details
Address for House Insurance
Street Address City Province Postal Code

This Application is for primary house insurance, where you live there as the homeowner.
Please Confirm If you Live in The House:
- Yes I Live in the House
- No I Live Elsewhere
Is Any Part Of The House Rented Out?
- Yes
- No
Is The Rented Portion of the House its Own Unit?
- Yes
- No
Unit: a portion of the house that has its own separate entrance, separate kitchen and bathroom and is not shared with other occupants of the house, other than the people living within that specific unit
What Year Was The House Built:
Type of Electrical Panel:
- Breakers
- Fuses
- Other
Electrical Panel Amperage
- 100
- 200
- More than 200
- Less than 100
Type of Wiring:
- Copper
- Aluminum
- Copper / Aluminum Mix
- Knob & Tube
- Mixed / Other
Other - Please Describe
Type of Heating
- Central Furnace
- Radiator / Boiler
- Electric Baseboard
- Other
Type of Heating - Other - Please Describe
Heating Fuel
- Natural Gas
- Propane
- Oil
- Other
Heating Fuel Other: Please Describe:
Any Fireplaces or Wood Stoves?
- Yes
- No
Type of Plumbing Supply Lines:
- Copper
- Pex
- Kitec
- Galvanized Steel
- Other / Mix
Other / Mix Plumbing Lines - Please Describe
Type Of Roof:
- Ashphalt Shingle
- Metal - Tile / Standing Seam
- Other
Other Type of Roof - Please Describe
Is There A Basment
- Yes - Finished 100%
- Yes - Finished 50%
- Yes - Finished Less than 50%
- No Basement
Does The Property Have A Backwater Valve Installed?
- Yes
- No
Does The Property Have A Sump Pump Pit?
- Yes
- No
Does The Sump Pump Have An Alarm with Battery Backup?
- Yes
- No
Is There A Garage
- Yes - Attached
- Yes - Detached
- No
Consent*
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