Home Insurance

Name:

Address:

City:

Province:

Postal Code (X1Y 2Z3):

Phone Number (123-456-7890):

Email:

Do you own your own home, own a condo unit or rent:

Homeowner

Condo Owner

Tenant

Estimated replacement value of dwelling: (homeowner only):

Estimated replacement value of personal property:

Policy deductible preferred:

Liability amount requested:

How many years have you consistently had a property policy in force:

Number of claims in the past 10 years:

How many years since last claim (if within 5 years):

Do you smoke:

Do you have a monitored alarm? (fire & burglary):

Do you have a mortgage/secured line of credit on the property:

What is your occupation:

Do you operate a business in the home:

Yes

How long have you lived at your current address?:

How many years since last time you moved:

What is your date of birth? (or date of birth of named insured person):

Was your prior policy canceled for non payment:

Was your policy lapsed for any other reason by the insurance company:

What is the amount of jewelry required to be scheduled:

Which insurance company has your current auto insurance:

Your Protection is Our Business

Atrens-Counsel Insurance Brokers, a division of Arthur J. Gallagher Canada Limited.