Application for Home Insurance

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General Info

First Name:	Last Name:
Address:	911#
City:	Postal Code:
Phone Number:	Email:

Current Home Insurance Information

Presently Insured:  Yes  No

If Yes, Company Name: Policy Number: Expiry Date:

Years of Continuous Hab Insurance:        Limit of Insurance:

Deductible:

Any Scheduled Articles (Jewellery, furs, cameras etc):  Yes  No   If Yes, Amount:

Home Information

Year Built:

Type of Heating: Natural Gas Electric Oil Propane Wood Age of Furnace (years): Age of Oil Tank (years):

If oil tank, where located:  Inside  Outside  |   Underground  Above Ground

Auxilliary Heating (select all that apply): Woodstove Gas Insert Other

Hydro Service: 200 amp 100 amp 60 amp  Breakers  Fuses Year of Hydro Service Update:

Roofing (select all that apply):  Asphalt Shingles  Steel  Other

Year of Roof Update:

Plumbing (select all that apply):  Copper  Plastic  Galvanized

Year of Plumbing Update:

Additional Liability Exposures:   Pool  Watercraft  Additional Properties

Hot Tubs  Parents in Nursing Home  Baby Sitting Done In Home  Part of House is Rented

Other  Other  Other  Other

Hydrant Protected:   Yes  No    Distance to nearest firehall (km):

Fire Alarm:  Yes  No    Burgler Alarm:  Yes  No

Monitored Alarm:  Yes No

Sump Pump:  Yes  No    If yes, what kind:  Automatic Battery Generator Water Powered

Does anyone in the house smoke:  Yes  No

Date of Birth of Eldest Insured(s): (dd/mm/yyyy)

Mortgage / Line of Credit:    Yes  No

Mortgagee Name:

Any Non-Payment Cancellations in last 3 years:  Yes  No

Any Claims in last 10 years:  Yes  No

If yes, were they water related:  Yes  No      Claim date: