Home Insurance Form

Home Insurance Form

268 Frederick St, Kitchener | (519) 743-6379 | carla@bollenbachinsurance.com
Applicant Name*

First NameLast Name
Insurance Coverage*

Property HomeownerCondoTenant
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Mailing Address if Different from Property Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Occupancy Date*

MonthDayYear
Soft Credit Check Consent*

YesNo
Date of Birth*

MonthDayYear
Previous Insurance Company:
How long with previous company?
Has any insurer cancelled or declined to renew in the last 6 years:   Yes   No*

How many years insured with any other insurer:

Property Information
Occupancy*

Primary ResidenceSeasonal/ Cottage
Year Built
Number of Stories*
Square Footage*
Smoker?*

YesNo
Structure Type*

DetachedSemi-DetachedTownhomeApartmentCondominium- townhomeCondominium- apartment
Construction Type:

If other, please specify:
Siding Type:

If other, please specify:
Protection:
Hydrant Firehall

Distance/Name:
Heating
Update Year:
Type:
Auxiliary:   Stove   Fireplace   Fireplace Insert   None
Fuel Type:

Additional Details:
Fuel Type
Roofing
Update Year:
Type:

Additional Details:
Garage
Number of Cars:
Type:
Electrical
Update Year:
Number of Amps:
Panel Type:   Breaker Panel   Fuse Panel
Wiring Type:

Additional Details:
Plumbing
Update Year:
Type:

Additional Details:
Hot Water Tank
Yes No

If yes, please provide year of water tank:blanks
Sump Pump

YesNoAuxiliary Sump
Do you have a generac generator?

YesNo
Number of Dogs and Breed Type*
Basement?*

YesNo
Bathrooms
Number of Full Bathrooms:   *
Number of Half Bathrooms:   *
Number of 3/4 Bathrooms:   *
Swimming pool?*

YesNo
Do you have a centrically monitored alarm?*

YesNo
Is there a mortgage? Yes No
If yes, how many?
Do you operate a business in your home? Yes No*
If yes, what type of business?
Do you rent any portion of your home?*

YesNo
Do you have any claims in the last 10 years? Yes No*
If yes, please provide details:
Current Coverage
What limit of insurance is on your home now?
What is the deductible?
What is the limit of liability?
What limit of sewer backup do you have?
Are there any floaters on your policy? (i.e. jewellery, boat, etc.)

If you are applying for Tenant Insurance, what limit of contents do you wish?
Effective Date of Coverage*

MonthDayYear
Date
Additional Comments
How did you hear about us?
Google SearchSocial MediaCommunity Event/AdvertisementReferral (friend/family)Other*

If Referral or Other, please specify:
Should be Empty:

Home Insurance Form

Property Information