Home Insurance
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Have you ever had insurance cancelled
or refused?
Yes     No
Do you currently insure your property?
Yes     No
Number of years prior insurance:
Expiry date with present Insurer
(dd/mm/yyyy)
What is your date of birth? (dd/mm/yyyy)
 
Property #1 Property #2
Property type:
Use:
Do you
Year built:
If property over 20 years old, which
of the following have been replaced?
Furnace
Roof
Wiring
Plumbing
Furnace
Roof
Wiring
Plumbing
Is property equipped with an alarm?
If yes, is 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
   
Discount Information  
I am mortgage-free
I am a non-smoker
   
Amount of coverage required  
Building:
Contents:
Liability:
Deductible:
   
Recent claims:
Type: Date (mm/yyyy) Location involved
#1:
#2:
#3:
Comments:
   
 


Your Protection is our Business
Atrens-Counsel Insurance Brokers