Home Insurance Quote Request Form Name* Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address City Postal Code Phone* Email* Any claims or losses in last 5 years?*Please SelectNoYesIf yes, please list type of loss / dates / amount paid / etc.Have you had your home insurance refused or cancelled?*Please SelectYesNoSpouse or Partner's Name Spouse or Partner's Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does anyone smoke in the household?*Please SelectYesNoDescribe Your Home*Please SelectDetached HomeSemi-detached HomeTown House / Row HouseDuplexTriplexCommercial BuildingMobile HomeProperty Located on a FarmOtherNumber of floors in your home?*Please Select1234What % of your basement is finished?*Please Select0%25%50%75%100%What type of construction is your home?*Please SelectFrame / WoodBrickOtherCarport Capacity*Please Select1 car2 cars3 or more carsWhat type of garage do you have?*Please SelectDetached - 1 carDetached - 2 carsDetached - 3 cars or moreAttached - 1 carAttached - 2 carsAttached - 3 cars or moreBuilt In - 1 carBuilt In - 2 carsBuilt In - 3 cars or moreBasement - 1 carBasement - 2 carsBasement - 3 cars or moreView garage guideWhat year was your home built? (approximately if not sure) Do you have a pool?*Please SelectYesNoWhat type of roof does your home have?*Please SelectAsphalt ShinglesCedar Shingles or ShakesSteel / MetalTar and GravelSlateConcrete TileIf roof has been replaced, what year? What is the primary source of heat?*Please SelectGasElectricPropaneSolarWood StoveHow many gas fireplaces?Please Select12345Any wood heat?*Please SelectYesNoDo you have any of the following? Central Air Conditioning Heat Pump None What type of alarm system do you have in your home?*Please SelectNoneLocal AlarmMonitored Alarm Just for BurglaryMonitored Alarm for Fire and BurglaryDo you have smoke detectors in your home?*Please SelectYes - BatteryYes - ElectricNoIs your home located within 300 metres (1000 ft) of a fire hydrant?*Please SelectYesNoIs your home located withing 8km (5 miles) of a fire hall?*Please SelectYesNoDo you have a built in sprinkler system?*Please SelectYesNoWho is occupying your home?*Please Select...You and Your Family MembersYou and 1 or 2 Boarders or RoommatesYou and 3 or more Boarders or RoommatesVacantIs there a separate suite in your home?*Please SelectYesNoHow many kitchens in your home?*Please Select12345How many mortgages on your home?*Please Select12More than 2Do you run a business from your home?*Please SelectYesNoReferring Agent*Please SelectDwayne GiesbrechtDale AllcockTeressa RichardsRuss MacnabJordan MacnabCarly MonradTony GovicJosh UrquhartMike MooreKayleigh KadulskiRebecca ValentineChloe UdotKyle ElderRachelle EriksenLynette SzabadosVicky DempseyJanel MayersAndrew IlaenderChase ShymkiwNoneHow did you find us?*Select...Friend/FamilyGoogle SearchFacebookReferralOtherAdditional CommentsCAPTCHA Δ