Home Insurance Quote Request
Please fill out this form as completely as you can to help us give you an accurate quote.
We'll get back to you as soon as possible. Don't forget to include your correct, complete name, phone number and email address.
***Please note we are unable to quote outside the provinces of New Brunswick and Nova Scotia.
Your Name:
Property address:
City:
Province:
Postal Code:
Day Phone:
Your e-mail:
Best time to contact:
Are you presently insured?
yes no
Present insurance carrier:
How did you learn about this website?
Dwelling Information
Protection
Within 100 feet of a fire hydrant Within 8 kms of a firehall Over 8 kms from a firehall
Primary Heating
Electric Oil Furnace Wood Furnace Combination Wood & Oil Furnace Heat Pump Other (Please explain in remarks)
Auxiliary Heat
None Wood Stove Fireplace Insert Pellet Stove Propane stove or insert Other (Please explain in remarks)
100 amp entrance 200 amp entrance
Year Built
Pre 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Update Details
If dwelling is over 20 years old please advise if any updates to the following
ROOFING: No Updates Partial Updates Fully Updated
Year Updated: - 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
WIRING: No Updates Partial Updates Fully Updated
HEATING: No Updates Partial Updates Fully Updated
PLUMBING:
No Updates Partial Updates Fully Updated
Year Updated:
- 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Any Claims in the last 10 years?
Claim #1
No Yes
N/A 2005 2004 2003 2002 2001 2000
None Fire Water Damage Windstorm Other
Claim #2
Claim #3
Discount Information:
Date of birth (month/day/year)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Is There a Mortgage on the property?
House protected by an alarm system?
no alarm Burglar Burglar & Fire
Type of alarm system
How long have you lived at your present address?
Does your present policy carry any of the following extensions;
Sewer Backup
Personal Computer
Floaters (ie jewellery, Fine Arts, computers)
Home Based Business?
Please add any comments that may help us with your quote.
Comments: