Home & Cottage Quote

Personal Information

Name

Contact person (if different)

Address - Street & City (Must reside in Manitoba, Canada)

Postal Code

Home phone

Business phone

Fax number

E-mail (We can not respond unless you provide your E-mail address)

Date of birth: Day Month Year

Details of your Home/Cottage

Do you wish to insure a Home or Cottage

Year built:

Number of stories (ie. 1, 2, split, bi-level):

Square footage of home:

Type of flooring (ie. carpet, hardwood, laminate, vinyl)

Finished basement: No Yes - if yes, percentage finished: %

Number of bathrooms: One Two Three Four

Attached garage: None One Car Two Car Three Car

Central air conditioning: No Yes

Swimming pool: No Yes

Deck or porch: Describe and advise size

Fireplace: No Yes

Alarm system: No Yes - if yes, is it monitored? No Yes

Age of furnace:

If heating is other than a gas furnace or electric please advise

Please describe any additional features of your home:

How long have you carried insurance?:

Amount of insurance you now carry on your house (building amount)
$

Riders can be added to specifically insure certain types of property. If you wish to add a rider to your policy please indicate values:

If your home/cottage is over 20 years old please advise the following:

Roof: When were the shingles last replaced?

Wiring: Circuit breakers or fuses
Number of amps (ie. 60, 100, 200)

Knob or tube wiring? No Yes

Plumbing: Type of plumbing (copper, plastic, galvanized)

Claims History

Please advise if you have had any claims or uninsured losses in the last 5 years.

Date of Claim	Type of Claim	Amount Paid

If outside of Winnipeg advise:

Is there a fire hydrant within 1000 feet? No Yes

Distance to the nearest responding fire hall