Name: 
     Address: 
        City:  Province: 
 Postal Code:  Phone:  FAX: 


 Have you changed address in the last 3 years: 
NO
YES
 If YES,
 provide previous address: 

  Occupation: 
        Number of years continously employed: 


 E-Mail Address: 

  How Should We Contact You With A Quote? 
E-Mail
Regular Mail
FAX
Phone

Address: 
   City:   Province:   Postal code: 

        This location is: 
within 300m of a fire hydrant.
within 8Km of a firehall.
beyond 8Km of a firehall.


                       Occupancy: 
primary
secondary
seasonal
rental
vacant
unoccupied
under construction


                     Structure Type: 
detached
semi-detached
townhouse
row-house
mobile home
duplex
triplex
multiplex
mercantile
highrise
appartment

                          If appartment or highrise,
                          state number of units: 

             Type of Heating:
central furnace
combo furnace with wood
combo without wood
furnace with add-on wood
space heater
electric
fireplace insert
wood stove

              If wood stove, additional information is
              required (please await proper form in mail).

                          Heating Fuel: 
wood
natural gas
coal
propane
other

           If other, please specify: 

Is this the primary or auxihilary heating source?

Construction:
Year built: 
Frame: 
brick veneer
masonary
fire resistant

Number of storeys: 
ground area (square feet): 

Rennovation updates:
Electrical: full  partial. Year of  Update: 

   Heating: full  partial. Year of  Update: 

  Plumbing: full  partial. Year of  Update: 

   Roofing: full  partial. Year of  Update: 

Security System:
smoke detectors 
No
Yes
  If Yes, how many: 
     Fire alarm 
No
Yes

  Burglar alarm 
No
Yes

Do you have:
  deadbolt locks on ALL exterior doors,
  fire extinguishers AND smoke detectors
  on ALL levels? 
No
Yes

Would you like to make monthly payments?

Who were you most recently insured with? What was your policy number? When does/did it expire?

To the best of you're knowledge:

Has any insurance company cancelled property insurance
in the last 5 years? 
No
Yes

If YES, please give details:

Describe all claims and losses within the last 5 years
including the following information:

      · Date of incident;          · Cause;          · Amount Paid;

Please use the following space to enter information regarding additional
locations, or other personal property, or any other information you feel
may be needed.




When would you like this quote by (number of days)?  

            


If Service is important to YOU, Service
 is number 1 with US!