Property Insurance Form

COMMENTS

Please take a moment to tell us how you heard about us:

Please tell us who refered you:
^*(If it was a friend please write their full name in the space below)

CONTACT INFORMATION

INSURANCE INFORMATION

Has your insurance ever been cancelled?

Yes No

Are you presently insured? If yes, what company?

Policy Number

Expiry Date

When would you like your coverage to begin?

What is your current annual premium?	$
Why are you looking for a new insurer or broker?

PROPERTY INFORMATION

Construction Type	Value of Personal Property	$
Year Built	Area (sq. feet)
Residence	Replacement Cost on Contents?	Yes No
Check or complete all fields applicable to your condominium:
Fireplace	Smoke Detectors
Fire Extinguisher	Fire Alarm
Burglar Alarm	Hydrant Protected
What is the approximate distance to the closest fire hall? (km)

COVERAGE INFORMATION

CLAIMS

THANK YOU!