House Quote Application

APPLICANT'S FIRST NAME    APPLICANT'S LAST NAME

APPLICANT'S POSTAL ADDRESS

STREET ADDRESS

CITY      PROVINCE      POSTAL CODE

CONTACT NUMBERS

HOME/CELL

BUSINESS

EMAIL ADDRESS

POLICY PERIOD

EFFECTIVE / RENEWAL DATE (YYYY/MM/DD) TIME     AM    PM

EXPIRY DATE (YYYY/MM/DD)

APPLICANT DATA

INSURED NAME            DATE OF BIRTH (YYYY/MM/DD)      OCCUPATION

CO-INSURED NAME      DATE OF BIRTH (YYYY/MM/DD)      OCCUPATION

RISK ADDRESS

SAME AS POSTAL ADDRESS

ADDRESS     CITY     POSTAL CODE

ACCESS

EASY ACCESS ROAD
DIFFICULT ACCESS ROAD
ISLAND
ISOLATED RURAL
OTHER

DO YOU HAVE MORTGAGE? yes   no   IF YES, HOW MANY?

RATING INFORMATION

YEAR BUILT        # OF STORY'S         # OF FAMILIES

TOTAL LIVING AREA (excluding basement)     SQ.FT   SQ.M.

SMOKER(S)?

OCCUPANCY

PRIMARY
SECONDARY
SEASONAL
RENTAL
VACANT
UNOCCUPIED
UNDER CONSTRUCTION

EXTERIOR WALL FRAMING

WOOD FRAMING
CONCRETE BLOCK/MASONRY FRAME
LOG
FIRE RESISTIVE

EXTERIOR WALL FINISH

BRICK
VENEER VINYL SIDING
STONE VENEER
SOLID BRICK
ALUMINUM METAL SIDING
WOOD

STRUCTURE TYPE/STYLE

DETACHED
SEMI - DETACHED
ROWHOUSE/TOWNHOUSE (END)
ROWHOUSE/TOWNHOUSE (INSIDE)
HIGHRISE
MOBILE HOME
MULTIPLEX

FOUNDATION

POURED CONCRETE
CONCRETE BLOCK
CRAWL SPACE
SLAB/CONCRETE SLAB
STONE

FINISHED BASEMENT %

HEATING TYPE

PRIMARY HEATING: FURNACE      OR      ELECTRIC      

If your primary heating is a furnace please specify if it runs on GAS   or   OIL

AUXILIARY HEATING: WOODSTOVE      OR      FIREPLACE

HEATING UNIT PROFESSIONALLY INSTALLED       HEATING UNIT ULC, CSA APPROVED

RADIANT HEATING AREA SQ.M.        MAKE       YEAR

SECURITY SYSTEM

LOCAL FIRE SYSTEM          MONITORED FIRE SYSTEM

LOCAL BURGLAR SYSTEM          MONITORED BURGLAR SYSTEM

LOCAL SMOKE DETECTORS          MONITORED SMOKE DETECTORS

NUMBER OF SMOKE DETECTORS           SPRINKLER          

SUMP PUMP: YES   NO

FIRE PROTECTION

UNPROTECTED           SUPERIOR SHUTTLE TANKER SERVICE

WITHIN M OF HYDRANT      WITHIN KM OF FIREHALL        FIREHALL NAME

OIL TANK

YEAR       INSIDE     IN GROUND    OUTSIDE    ABOVE GROUND

UPDATES IF YOUR HOME IS OVER 20 YEARS OLD

    1. HEATING

    HEATING:  FULL    PARTIAL   UPDATE YEAR

    2. ROOFING

    ROOFING:  FULL     PARTIAL     ROOFING TYPE    UPDATE YEAR

    3. ELECTRICAL

    AMPS

    BREAKERS    KNOB & TUBE    COPPER    FUSES    ALUMINUM

    4. PLUMBING

    COPPER %   PLASTIC %        GALVANIZED %   OTHER %        

FLOORS must equal to 100%

HARDWOOD %       CARPET %      CERAMIC %      OTHER %

NUMBER OF BATHROOMS

FULL       PARTIAL    

AIR CONDITIONING - A/C

CVAC - CENTRAL VACUUM:  YES    NO   

DECK:  YES    NO   IF YES, HOW MANY SQ. FT. ?

PORCH:  YES    NO   IF YES, HOW MANY SQ. FT. ?

SWIMMING POOL

YEAR       ABOVE GROUND      IN GROUND      WITH FENCE      WITHOUT FENCE

GARAGE/CARPORT

ATTACHED GARAGE          SIZE - # OF CARS      BUILT-IN

ATTACHED CARPORT          SIZE - # OF CARS

BASEMENT

LOSS HISTORY

CLAIMS HISTORY REPORT DATE (YYYY/MM/DD)

HAVE THERE BEEN ANY LOSSES OR CLAIMS BY THE APPLICANT IN THE PAST 5 YEARS YES   NO
IF YES COMPLETE THE CHART BELOW

POLICY HISTORY

FIRST TIME INSURED

HAS ANY INSURANCE COMPANY REFUSED TO PROVIDE INSURANCE IN THE PAST 5 YEARS? YES NO

IF YES, INDICATE INSURANCE REFUSAL TYPE
CANCELLED
DECLINED
REFUSED RENEWAL
RESTRICTED COVERAGE

BY WHICH INSURANCE COMPANY      REASON

PREVIOUS INSURANCE COMPANY
POLICY NUMBER      EXPIRY DATE (YYYY/MM/DD)

SINCE WHAT DATE HAS THE APPLICANT HAD HABITATIONAL INSURANCE
WITH ANY INSURANCE COMPANY (YYYY/MM/DD)

SECURITY CODE

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