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Homeowners Quote

Completion of this form is for informational purposes only, and is just an estimate. This WILL NOT result in a new policy, or change to an existing policy.

This quote is an estimate based on a single family home with standard central heating

APPLICANT INFORMATION

First Name	Last Name
Address	Phone
City	Phone 2
Province	E-Mail
Postal Code	Contact Method	Phone Email
INSURANCE HISTORY

Has your insurance ever been cancelled?	Yes No	Are you presently insured? If yes, what company?
Policy Number		Expiry Date
Building Value		Contents Value
Number of claims in the last 5 years
GENERAL INFORMATION

Building Type:

What year was this home built ? :

Is this home within 1000 feet of a fire hydrant and 5 Miles of a responding fire hall

Please indicate the type of central heating

Please select back up heating type:

Do you want Earthquake Coverage Yes No

Remember, that all policies contain limits on certain types of personal property such as jewelry, cash, bicycles. In most cases, these limits can be increased or a specific item can be added to a "rider or floater". Usually, the item added is not subject to the policy deductible.

SAVE with a higher policy deductible. Most policies today come with a $ 500 Deductible. . Consider increasing your policy deductible to $1,000 and save $75 or more per year on your insurance premium. Simply make a note in the comments section below.

If your home was built prior to 1992 or is located near a body of water, river, lake or ocean, you may need more protection for increased costs due to building codes and by-laws. Ask a Bakes Jarvie professional about additional By-Law Protection.

Live near a golf course or ball field ? Consider a separate glass policy starting at $ 35.00 a Year with no deductible.

Are you over 50 years old

Yes No

Are you mortgage free

Yes No

Do you have a monitored burglar alarm

Yes No

Do you run a business from home

Yes No

Is your home on acreage

Yes No

How many acres

SCHEDULED ITEMS DESIRED

Jewelry	Yes No	Value:
Sports Equipment	Yes No	Value:
Cameras	Yes No	Value:
Other	Yes No	Value:
Comments