Habitational Insurance Form
Please complete this application for an insurance quote.
Personal Info
Name on Title
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Additional name on title?
*
Yes
No
Name on Title
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Additional name on title?
*
Yes
No
Name on Title
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Years Employed
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Insurance Info
Do you currently have habitational insurance? (Home, Condo, Tenant etc..)
*
Yes
No
Current Insurance Company
*
Renewal Date
-
Month
-
Day
Year
How many years have you had habitational insurance?
Have you ever been cancelled by your insurance provider?
*
No
Yes
Reason for Cancellation
*
Date of Cancellation
*
-
Month
-
Day
Year
Any claims in last 5 years?
*
No
Yes
Please provide details on date(s), type(s) of loss and claim payout(s).
*
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Property Info
Policy Type
*
Please Select
Homeowners
Condo
Rental Property
Rental Condo
Cottage
Tenants Pack (Apartment/Condo)
Tenants Pack (House)
Risk Address
*
Street Address
Unit Number
City
Province
Postal Code
How many years have you owned or occupied this address?
*
# of Mortgages
*
Is any mortgage with a non-conventional or private lender?
*
Yes
No
Year Built
Square Footage (Excluding basement)
*
# of Storeys
# of Bathrooms
# of Bedrooms
# of Kitchens
# of Rental Units
*
How many families/tenants in occupancy?
*
Square Footage Breakdown of each Unit
*
Do all tenants have an annual lease agreement?
*
Yes
No
Is there any short-term rental exposure or subletting? (AirBnb, VRBO etc...)
*
Yes
No
Basement Finished %
Please specify if there is no basement
Garage Size
None
1 Car
2 Car
3 Car
More
Do you lease any portion of the property out to tenants?
*
No
Yes
Is the property currently under construction or are renovations planned?
*
No
Yes
Is the property vacant?
*
No
Yes
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Updates to Property
Please answer to the best of your ability
Electrical
Year of last Electrical update?
*
Wiring type
*
Copper
Aluminum
Knob & Tube
Panel Type
*
Breakers
Fuses
Service Amperage (amp)
Plumbing
Year of last Plumbing update?
*
Plumbing Type
*
Copper
PEX
PVC
ABS
Other
Water Heater Year of Manufacture
*
Water Heater Type
*
Please Select
Tank
Tankless
On-demand
Heat Pump
Other
Roof
Year of last Roof update?
*
Roof Material
*
Please Select
Asphalt Shingles
Metal/Steel
Wood
Rubber
Tar/Gravel
Other
Heating
Year of last Heating update?
*
Type of Heating
*
Please Select
Central Gas
Propane
Oil
Electric
Water/Steam
Other
Do you use a wood burning fireplace?
*
No
Yes
Type of Fireplace
*
Built-In (Traditional)
Fireplace Insert
Stove
Other
Year Installed
*
# of Annual Bush Cords
Is it WETT Certified?
*
Yes
No
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Optional: Potential Discounts
Do you have a centrally monitored burglar alarm?
Yes
No
Do you have a centrally monitored fire alarm?
Yes
No
Do you have a sump-pump?
Yes
No
Do you have a backwater valve?
Yes
No
# of Smoke Detectors
Do you have an auto you would like to pair up for a multi-line discount?
Yes
No
Submit
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