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Home Owner’s Insurance Quote Form
Please complete the following form to receive a quick quote.

Personal Information
         
First Name:
 
Last Name:
         
Date of Birth:
 
Current Occupation:
 

Additional Named Insured:
 
Date of Birth:
 
Current Occupation:
         
Address:
   
 
City/Town:
  
Province:
   
 
Postal Code:
 
 
   
 
Home Phone:
 
Work Phone:
   
 
Fax:
  
Email:
   
 
Have you ever had an automobile insurance policy cancelled or declined?
Yes No
   
 
Have you had any claims in the last 5 years?
Yes No
         
If yes, please provide details:
   
 
Type of Coverage?
Home Condominium Tenant
 
Do you currently have insurance? Yes No
 
If yes, currently insured for:
 
 
If yes, type of policy:
 
Value of dwelling
(if applicable):
 
Value of Contents:
 
Year Built:
 
Type of Home:
 
Number of Stories:
 
Construction:
 
Distance to nearest fire hydrant:
 
Distance to nearest fire station?
 
Required Dimensions
Main Floor Square Footage:
 
Porch:
 

Deck:

  
 
Finished Basement?
Yes No
  
Percentage Complete:
 
Walk Out Basement?
Yes No
  
Rental Unit?
Yes No
 
Upgrades:
Roof:
 
Furnace:
 
Wiring:
 
Plumbing:
 
 
Type of heat:
 
If oil, age of tank:
 
Central Air:
Yes No
  
Number of fire places:
 
Number of 2 piece bathrooms:
 
Number of 3 piece bathrooms:
       
Garage:
Yes No  
Type of garage:
       

Special Additions: Please list all relevant details:
         
Security Alarm:
Yes No  
Wired/Local:
         
Do you have a mortgage:
 Yes No      
         

Please provide details of any claims in the last 5 years:
         

1262 Bedford Highway Bedford, Nova Scotia Canada B4A 1C7
Tel: (902) 835-1262 Fax: (902) 835-2604 Toll free 1-877-925-2285