CHOOSE THE OFFICE CLOSEST TO YOU:
*
Please Select
Saint John
Campobello
St. Andrews/Chamcook
St. George
PERSONAL DETAILS
FULL NAME:
*
First Name
Last Name
EMAIL:
*
example@example.com
PHONE NUMBER:
*
Date of Birth:
-
Month
-
Day
Year
Date
PREFERRED METHOD OF CONTACT:
email
phone
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DETAILS
Date You Wish For Your Insurance To Start:
-
Month
-
Day
Year
Date
Date First Moved Into Location:
-
Month
-
Day
Year
Date
Years of Continuous Property Insurance:
Any Previous Property Claims?
Yes
No
Any Lapses of Insurance?
Yes
No
ANY SMOKERS?
Yes
No
Description and Date of Claims:
Date and Description of Lapse:
IS THERE A FIRE HYDRANT ON THE ROAD?
Yes
No
NEAREST FIRE HALL:
Please Select
Within 3 KM
Within 8 KM
Within 13 KM
Over 13 KM
NUMBER OF SMOKE DETECTORS IN HOME:
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
YEAR HOUSE WAS BUILT:
SQUARE FOOTAGE:
Number of Stories in Building
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NUMBER OF UNITS IN BUILDING:
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
What floor is the unit on?
Number of BedroomS in the unit?
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Bathrooms in the unit?
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Is There a Secured Entrance?
Yes
No
Is There A Sprinkler System?
Yes
No
TYPE OF ROOF:
Please Select
Asphalt/ Fiberglass Shingles
Cedar Shingles/ Shake
Clay Tile
EPDM Membrane
Metal/ Steel
Rubber
Slate
Tar and Gravel
TPO Membrane
Wood Shake
Wood Shingles
Other
YEAR OF LAST UPDATE TO ROOF:
MAIN SOURCE OF HEATING:
Please Select
Electric
Oil
Propane
Wood
Hot Water/ Steam
Coal
YEAR OF LAST UPDATE TO HEATING:
TYPE OF PLUMBING:
Please Select
Copper
Lead
Cast Iron
Galvanized Steel
Plastic
Mix - Copper/ Plastic
Other
YEAR OF LAST UPDATE TO PLUMBING:
SEWER BACK-UP PREVENTION DEVICE?
Yes
No
WIRING MATERIAL:
Please Select
Copper
Aluminum
Knob and Tube
Mixed
Other
YEAR OF LAST UPDATE TO ELECTRICAL:
Amount of Contents coverage required (Minimum $25,000) *
*
SEWER BACK-UP / EXTENDED WATER COVERAGE?
Yes
No
OVERLAND WATER COVERAGE?
Yes
No
SERVICE LINE COVERAGE?
Yes
No
Identity Theft Coverage
Yes
No
CLAIMS FORGIVENESS COVERAGE?
Yes
No
ANY SPECIALTY/HIGH VALUE ITEMS YOU’D LIKE SCHEDULES? PLEASE DESCRIBE:
ANY ADDITIONAL DETAILS YOU’D LIKE TO SHARE? PLEASE DESCRIBE:
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