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| Name: |
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| Address: |
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| City: |
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| Province: |
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| Postal Code: |
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| Phone Number: |
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| Email Address: |
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| Have you ever had insurance cancelled or refused? |
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| If yes, please choose: |
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| Expiry/Renewal Date: (dd/mm/yyyy) |
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| Existing/Prior Insurance Company Name: |
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| Existing/Prior Policy Number: |
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| What is your date of birth? (dd/mm/yyyy) |
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| Property type: |
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| Use: |
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| Do you |
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| Year built: |
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| If property over 20 years old, which of the following have been replaced? |
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| Is property equipped with an alarm? |
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| If yes, is alarm |
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| Proximity to fire services: |
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| Discount Information |
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| I am mortgage-free |
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| I am a non-smoker |
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| Amount of coverage required |
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| Building: |
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| Contents: |
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| Liability: |
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| Deductible: |
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| Recent claims: |
| Type: |
Date (mm/yyyy) |
Location involved |
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| #1: |
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| #2: |
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| #3: |
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| Comments: |
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Disclaimer |
