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Listing and/or inspection (if possible)
Previous insurance information
Your Lender’s information
Your Lawyer’s name and fax number
Void cheque/banking letter (if interested in a monthly payment plan)
First Name
*
Last Name
*
Date of Birth
*
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Email
*
Phone
*
Name of Additional Person on Policy
Date of Birth
Month
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1921
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Property Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
What is your preferred method of contact?
*
Phone
Email
How did you hear about us?
*
Google
Social Media
Radio
Referral
Events
Mascot
Tell us about your property
What year was your home built?
*
Square Footage
*
Above Ground
Architecture Style
*
A-Frame
Log
Bungalow
Raised Bungalow
Bilevel
Modified Bi-Level
Tri-Level
1.5 Story
2 Story (1950 or newer)
2 Story (Pre-1950)
4 Level Split
Semi-detached
Townhouse
Duplex
Fourplex
Other
Construction Type
Average
Above Average
Custom
Average – Materials for this house would typically be found at a major building material store chain.
Above Average – A house of this quality is sometimes called a “Spec House” & is usually an upgraded version of a builder’s plan with high quality materials. A few of the rooms or part of the house are customized for the owner.
Custom – Materials for this house would be purchased at boutiques or specialty stores. Designers are usually involved. The entire home was “customized” for the owner.
Foundation Type
Basement - Finished
Basement - Unfinished
Basement - Partially Finished
Walkout Basement - Finished
Walkout Basement - Partially Finished
Walkout Basement - Unfinished
Crawlspace
Slab
Basement Square Footage
*
Number of Full Bathrooms (Toilet, Sink, Tub, and Shower)
Please enter a number from
0
to
10
.
Number of Half Bathrooms (Toilet and Sink)
Please enter a number from
0
to
10
.
Number of Three-Quarter Bathrooms (Toilet, Sink, and Shower)
Please enter a number from
0
to
10
.
Primary Exterior Wall Material
*
Vinyl
Wood
Stucco
Hardboard
Aluminum
Brick
Log (greater than 11” diameter)
Log (less than 11” diameter)
Cement Fiber
Cedar Siding
Clapboard
Metal Siding
Other
Other External Wall Material
Physical Shape of the Home
*
Angular (few to no right angles)
Complicated
Contemporary
Curvy (extensive curves)
H-shaped
L-shaped
Octagonal
Rectangular
Rectangular with angled wing
Rounded
Square
T-shaped
Unique
Other
Primary Roof Material
*
Asphalt
Fiberglass
Aluminum
Wood Shake
Metal
Clay
Cedar Shingle/Shake
Cement Fiber
Rubber
Wood Shingle
Other
Roof Installation Date
*
Does the home have a garage?
*
Yes
No
Garage Style
*
Attached Single
Attached Double
Detached Single
Detached Double
Other
None
Garage Year Built
*
Garage Size
*
1 Car Garage
2 Car Garage
3 Car Garage
4 Car Garage
Other
Is the Garage Heated?
*
Yes
No
Property Details
Does this home have any of the following?
Deck
Porch
Breezeway
Solarium (sun room)
Carport
Pool/All Weather Pools
Hot Tub
Solar Panels
Deck Square Footage
*
Deck Style
*
Covered
Enclosed
Open
Screened
Year-Round
Deck Type
*
Rooftop
Specialty Wood
Synthetic Lumber
Wood
Deck Year Built
*
Porch Square Footage
*
Breezeway Square Footage
*
Solarium Square Footage
*
Carport Square Footage
*
Pool Square Footage
*
Hot Tub Size
*
2 People
2-4 People
6+ People
Has the home been completely gutted in the last 40 years?
*
Yes
No
Is the home listed on the historic registry?
*
Yes
No
What is this homes primary heating type?
*
Central Furnace
Electric
Boiler
Solid Fuel
Other
When was the heating last replaced?
*
Does the home have auxiliary heat?
*
Yes
No
Auxiliary Heat Type
*
Wood Stove
Wood Burning Fireplace
Wood Burning Insert
None
Auxiliary Heat Fuel Type
*
Natural Gas
Oil
Propane
Wood
None
Electrical Panel
*
60 Amp
70 Amp
100 Amp
200 Amp
Wiring Type
*
Aluminum
Copper
Knob & Tube
If the home has aluminum or knob & tube wiring, an electrical inspection will be required prior to coverage being issued
Plumbing Type
*
Plastic
Copper
Cast Iron
Lead
Other
Water Heater Type
*
Tank
Tankless
When was the water heater last replaced?
*
Does the home have a backwater valve?
Yes
No
Backwater Valve Type
*
Gate
Flapper
Does the home have a sump pump?
*
Yes
No
Sump Pump Type
*
Submersible
Pedestal
Description of Locale
*
Gated Community
Island (accessible by boat only)
Island (accessible by bridge)
Remote (Moderate)
Remote (Slight)
Remote (Very)
Resort
Rural
Suburban
Town
Urban
Waterfront
Will you have a 24 hour third party monitored alarm system? (example: SecurTek, ADT)
*
Yes
No
Is the home more than 13 kms away from a responding fire hall?
*
Yes
No
Occupant Type
Owner
Rented Room(s)/Suite
Rented to Others
How many People/Families?
*
Is the home family occupied?
Yes
No
Does the home have a basement suite?
*
Yes
No
Full Name of Occupant
*
Date of Birth of Occupant
*
Possession date or current renewal date
*
Month
Month
1
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Day
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Year
Year
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Do you currently have property insurance?
*
Yes
No
Continuously insured for:
*
1 year
1-4 years
5+ years
Have you experienced any property claims in the past six years?
*
Yes
No
Do you have a mortgage or homeowners line of credit?
*
Yes
No
Which bank is this line of credit with?
Soft Credit Check
*
(soft credit check has no impact on your credit score)
Yes
No
Additional Notes/Comments
Include scheduled property (Jewelry, Watercraft, ATVs, etc.)