Contact Information
Your Name:
Your phone number:
Your email address:
City, Province:
Your Date of birth:
Residence Information
Postal Code of the residence:
What type of insurance do you need?:	Tenant Renters
City:
Describe the residence (Condo, Townhouse, Detached, etc):
What is building replacement cost?:
How old is residence:
What is the primary method of heating in the residence?:
What type of alarm system do you have?:
How close to your property is the nearest fire hydrant?:
Residence Insurance History
How long have you had a home insurance policy?:
How many home insurance claims have you had in the last 5 years?:
In the past 5 years, have you had a home insurance policy cancelled by an insurance company or has an insurer ever refuse to insure this residence?:
Additional Information
Do you want discount with additional insurance coverages (vehicle) ?
Additional comments: