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| Name: |
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| Address:
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| City: |
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| Province:
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| Postal Code:
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| Phone Number:
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| Email Address:
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Have you
ever had insurance cancelled
or refused? |
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| Do you currently
insure your property? |
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| Number of
years prior insurance: |
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Expiry date with present Insurer
(dd/mm/yyyy) |
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| What is your
date of birth? (dd/mm/yyyy) |
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| Property type:
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| Use: |
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| Do you |
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| Year built:
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If property
over 20 years old, which
of the following have been replaced? |
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| Is property
equipped with an alarm? |
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| If yes, is
alarm |
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| Are you within
300 m of a hydrant? |
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| Are you within
13 km of a firehall? |
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| Discount
Information |
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| I am mortgage-free
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| I am a non-smoker
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| Are you a member of one of these associations? |
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| Amount
of coverage required |
| Building:
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| Contents:
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| Liability:
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| Deductible:
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| Recent claims:
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| Type: |
Date (mm/yyyy) |
Location involved |
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| #1: |
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| #2: |
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| #3: |
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| Comments:
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