Quote

Residential

Name*:

Address:

City:

Province:

Postal Code*:

Telephone*:

E-mail address*:

Have you ever had insurance cancelled or refused?*

Yes

Is your property currently insured?*

Yes

Please provide information of your last residential insurance policy.

Insurer:

Policy number:

Expiry date:

When should coverage start?

What is your date of birth?

Property Information:

Property type*:

Principal home

Cottage (Seasonal)

Cottage (Year-Round)

Rented property

Other

Do you …:*

Own

Rent

Year of construction:

the property id over 20 years old, which of the following have been replaced?

Furnace

Roof

Wiring

Plumbing

Is the property equipped with an alarm?*

Burglar only

Fire only

Fire and burglar

If yes, is the alarm…

Local only

Monitored by company

Does the property have a pool?*

Yes

Proximity to fire services*:

300 m from fire hydrant

8km from fire station

neither

Discount Information*

I am mortgage-free

I am a non-smoker

Amount of coverage required:

Building*:

Contents*:

Liability*:

$ 500 000

$ 1 000 000

$ 2 000 000

Deductible*:

$ 300

$ 500

$ 1 000

Recent claims:

Date:

Break-in

Fire

Water damage

Other

Comments:

(*) Obligatory fields

5993, rue Jean-Talon Est, suite 202, Montreal (Quebec) H1S 1M5 • Phone: (514) 253 - 8960 • Fax: (514) 253 - 5860