Name:
	Email Address:
	Address:
	City:
	Province:
	Postal Code:
	Phone Number:
	Do you own your own home, own a condo unit or rent?	Homeowner
		Condo Owner
		Renter
	Estimated replacement value of dwelling (homeowner only)
	Estimated replacement value of personal property (condo & renters only)
	Policy deductible preferred:	$200 $300 $500 $1000
	Liability amount requested:	$500 000 $1 million $2 million
	Have you had any claims in the last 5 years?	Yes     No
	Date of Birth of Owner:	/ / yyyy mm dd
	Number of Families in household:
	Is property within: 1000 ft of Hydrant?	Yes     No
	Is property within: 8 km of a responding fire hall?	Yes     No
	Is property unprotected?	Yes     No
	Year home was built:
	If over 25 years old, we require the year of update on ...
	Roof :
	Heating :
	Plumbing :
	Electric Panel :
	Type of Heating in home :
	Any woodstove(s) in or outside of home?	Yes     No
	If yes, is stove CSA/ULC approved?	Yes     No
	Is there a mortgage on the home?	Yes     No
	Seasonal Cottage
	Address:
	City:
	Province:
	Postal Code:
	Year cottage was built:
	Is cottage used summer only / year round:	summer only year round
	Is it Firehall protected or unprotected:	protected unprotected
	Type of Heating:
	Any woodstove(s) in or outside of cottage:	Yes     No
	If yes, is stove CSA/ULC approved:	Yes     No
	Amount of insurance required on Building, Guest House, Garage, Boathouse, Shed, Other:
	Amount of insurance required on Contents:
	Any claims in last 5 years:
		Disclaimer

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