Please note that this form does not support Internet Explorer. First Name* Last Name* Email* Phone* Date of Birth* What is the physical address of your home?* Please include your City or RM and postal code Secondary Applicant First Name Last Name Date of Birth Second Applicant Are there any smokers in the household? YesNo May the quoting companies collect your credit score? Some companies give an additional discount based on your Credit Score. Please note that this will not affect your credit rating or history and your credit information will not be shared with any third parties, including us. YesNo What will be the effective date?* Normally either the possession date of your new home, or the renewal date of your existing policy. How many years have you held personal insurance in your name(s) (Homeowners, Tenants or Condo) 10+ Years4-9 Years1-3 YearsI have never held personal insurance in my nameI have previously had person insurance, but it has lapsed/cancelled for more than one month How many claims have you had in the last 5 years? 0123+ Have you ever had a policy cancelled, lapsed, or declined? YesNo If yes, please explain. General Details Fire Protection Fire Hydrants within 300 m and Firehall within 8 kmResponding Firehall within 8 km, no Fire HydrantsResponding Firehall between 8-13 km, no Fire HydrantsResponding Firehall over 13 km, no Fire HydrantsNo Hydrants or Firehall Do you run a business out of your home? YesNomaybe If yes, please describe. Do you own any other locations? (e.g. cottage or rental property)? YesNo Home Details Please provide some details about your primary residence. What is the square footage of your home (not including basement)?* What year was your home built?* How many stories is your home?* 1 Storey1-1/2 Stories2 StoriesBi-LevelOther What is the physical shape of your home?* SquareRectangleContemporaryL-ShapedOther What comprises the majority of the siding on your home?* StuccoVinylBrickOther How many Bathrooms in your home? Full Bathrooms 0123More Half Bathrooms (Toilet & sink) 0123More 3/4 Bathrooms (Toilet, sink & shower) 0123More Roofing Type* Asphalt or Fiberglass ShinglesMetalWood ShinglesOther What year was the roofing last replaced?* Please describe your basement* Below GradeWalk-outCrawl SpaceSlab Is your basement finished?* Yes, Fully FinishedYes, Partially FinishedNoN/A Please describe your garage Attached None1 Car2 Car3+ Cars Detached None1 Car2 Car3+ Cars Carport None1 Car2 Car3+ Cars Sheds, gazebos, workshops or other structures: YesNo How big is your porch, deck and/or sunroom? (describe each)* How big is your porch, deck and/or sunroom? (describe each)* Do you have a hot tub? YesNo Do you have a pool? YesNo What kind of plumbing do you have in the house?* Select all that apply. CopperPlastic (PVC or PEX)GalvanizedOther Other: Please identify What kind of water and backup protection do you have?* Select all that apply. Sump pump in a pitIn-line backwater valveCentrally monitored water alarmNoneOther Other: Please identify What kind of wiring is in your house?* Select all that apply. CopperAluminumKnob & TubeOther Other: Please identify Describe your electrical panel.* Select all that apply. FusesCircuit Breakers - 60ampCircuit Breakers - 100 ampCircuit Breakers - 200 amp or moreOther Other: Please identify How is your home heated?* Select all that apply. Forced Air - Natural GasForced Air - ElectricBoilerElectric BaseboardsGeo-ThermalOther Other: Please identify What year was your heating last replaced?* Do you have a wood stove or other solid fuel heating apparatus? YesNo Please describe any other features of the home, not listed above, that may affect the value of the home? Describe your alarm system Professionally installed Burglar AlarmMonitored Burglar AlarmMonitored Burglar and Fire AlarmNo Alarm Other: Please identify Please provide the name of the company that installed and/or monitors the alarm. Do you currently or will you have a Mortgage or Line of Credit secured against your home? YesNo If Yes, which institution? Do you have a lawyer that is looking for proof of insurance? YesNo If Yes, please provide their contact information. If this insurance is for a new home or you have lived in this home for less than 3 years, please provide your previous address. Consent and Disclosure: By selecting "I agree" below, you are authorizing us to contact you regarding your insurance. You are also declaring that all the information you have provided is true, correct and complete, to the best of your knowledge. You also understand that any information that has been incorrectly entered may affect the premiums quoted. In the event an insurance contract is accepted by you, willfully misrepresenting any information may void the insurance or be considered insurance fraud punishable by law. I agreeI disagree