House Information

1.

$100,000.00$120,000.00$140,000.00 $160,000.00$180,000.00$200,000.00 $220,000.00$240,000.00$260,000.00 $280,000.00$300,000.00Over 300,000.00Other

2.

Deductible required

$200.$500.$1,000.$2,500.

3.

Limit of liability coverage required

$1,000,000.$2,000,000.

4.

Type of Structure

DetachedSemi-AttachedApartment

5.

Construction of building

FrameBrickConcreteSteel

6.

Year building constructed

7.

Is there rental of any portion of the home

NoYes

8.

Type of heating

electricgasheat pumpother

9.

Wood Heat

NoYes

10.

Fire Protection

Within 1000 ft fire hydrantWithin 5 miles of fire hallUnprotected

11.

Mature Age Discount Applies

To see if you apply please enter the

Date of Birth of Oldest member of household:
   (DD/MM/YYYY)

12.

Alarm System

YesNo
If yes, 
Local Alarm OnlyAlarm Monitored for burglary onlyAlarm monitored for burglary & fireNone

13.

Mortgage Free Discount Applies

YesNo

14..

Years Continuously Insured Claimsfree

Never Insured Before1 year No Claims Experience2 years No Claims Experience3 years No Claims Experience5 years No Claims Experience10 years No Claims ExperienceOther

15.

Additional coverages required

Yes No 
     If yes, please give details:

16.

Have you had any losses in the
last 3 years?

     If so, give details & claims amount

Name

Address

City

Postal Code

Email Address

Telephone #

Fax #

  Please check over all your entries above before submitting