Tenant Insurance Quote Request Form

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Company

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Name*

Date of Birth*

Address*

Street Address City Province Postal Code

Phone*

Email*

Any claims or losses in last 5 years?*

If yes, please list type of loss / dates / amount paid / etc.

Have you had your home insurance refused or cancelled?*

Spouse or Partner's Name

Spouse or Partner's Date of Birth

Does anyone smoke in the household?*

Describe Your Home*

What type of construction is your home?*

What year was your home built? (approximately if not sure)

Do you have a pool?*

What is the primary source of heat?*

Any wood heat?*

What type of alarm system do you have in your home?*

Do you have smoke detectors in your home?*

Do you have a built in sprinkler system?*

Is your home located within 300 metres (1000 ft) of a fire hydrant?*

Is your home located withing 8km (5 miles) of a fire hall?*

Who is occupying your home?*

Is there a separate suite in your home?*

Do you run a business from your home?*

Referring Agent*

How did you find us?*

Additional Comments

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