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Friday 9am - 4pm
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How did you hear about us?
Name:
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Address:
City:
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Province:
Postal Code:
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Phone Number:
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Email Address:
Preferred Method of Contact:
Have you ever had insurance cancelled or refused:
Yes No
Do you currently insure your property:
Yes No
Have you lived at your current address for more than 3 years:
Yes No
Number of years prior insurance:
Expiry date with present insurer (dd/mm/yyyy):
What is your date of birth: (dd/mm/yyyy):
Property Type:
Use:
Do you:
Own Rent
Year Built:
If property over 25 years, which of the following have been replaced or updated:
Furnace
Roof 		Wiring
Plumbing
Is property equipped with alarm:
Yes No
If yes, is your alarm:
Local Monitored
Are you within 300 m of a hydrant:
Yes No
Are you within 13 km of a firehall:
Yes No

Discount Information:
  
I am mortgage free:
Yes No
I am a non-smoker:
Yes No

Amount of coverage required:
  
Building:
Contents:
Liability:
 $1,000,000 $2,000,000
Deductible:
 $500 $1,000
   
Recent Claims:
Type
1.
2.
3.
Date (mm/yyyy)
Comments:
   

 


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304 Toronto Street South, Suite #204, Elgin Centre, Uxbridge, ON L9P 1Y2
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