Powerful Protection, Priced Right - Home, Farm, Auto, Life, & Travel Insurance
HOME SITEMAP CONTACT
Home Insurance
Tenant Insurance
Farm Insurance
Auto Insurance
Life Insurance
Specialty Insurance
Business Insurance

Name:
Address:
Phone (Home):
City:
Phone (Work):
Province:
Email Address:
Postal Code:

Have you ever had insurance cancelled
or refused?
 Yes No
Do you currently insure your property?
 Yes No
If currently insured - who is your insurer?
SGI MMFI
SMI AVIVA
WAWA Other
CO-OP  
Number of years prior insurance:
Expiry date with present Insurer
(dd/mm/yyyy)


  Person #1   Person #2
What is your date of birth? (dd/mm/yyyy)
  
First Time Homeowner: Yes No
Type of Home:
1 Storey
2 Storey
Tri-level
Other
Property #1   Property #2
Property type:
 
Use:
  
Do you:
 
Year built:
 
If property over 20 years old, which
of the following have been replaced? If so when?
Item Year   Item Year
Furnace   Furnace
Roof   Roof
Wiring   Wiring
Plumbing   Plumbing
Is property equipped with a alarm?
 
Are you within 300 m of a hydrant?
 Yes No   Yes No
Are you within 13 km of a firehall?
 Yes No   Yes No

Amount of coverage required - ( Most homes have to be ensured for replacement value. A detailed calculation will need to be done. As a rough guide assume $220 per sq. ft. )
Building:
 
Contents:
 
Liability:
 
Deductible:
 
Discount Information
I am mortgage-free Yes No
I am a non-smoker Yes No


Recent claims:
Type:
Date (mm/yyyy)
Location involved:
#1:
#2:
#3:
Comments:


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