Personal Information

First Name
Last Name
Possession / Expiry Date:
Address
Postal Code
Email
Phone
Previous Insurance
Referred by

House information

Year Built
Sq FT
Number of Stories
Foundation Type
Finished Basement
Primary Exterior Siding
Primary Flooring
Number of Bathrooms
Type of Heating
A/C
Deck/Porch
Pool
Wood Heat
Fireplace
Garage

Scheduled Items

Jewellery
Furs
Collections
Fine Arts
Boat/Motor

Updates

Roof
Year
Type
Plumbing
Year
Type
Wiring
Year
Type

Additional Coverage

Sewer Backup
Sump Pump
Backup Valve
Contents in Storage
Bylaws
Liability Limit
Identity Theft
Broad or Comprehensive Coverage
Deductible
Reduced Glass
Business in home?
Day Care?
Business Tools

Discounts

Occupation
Date of Birth
Claims Free
Alarm
Number of Water Sensors
Mortage Free
Non-Smoker
How long have you lived at this location?
Additional Comments