For manual submission, download this form here.
HOMEOWNER QUESTIONNAIRE
TO BE COMPLETED AND SIGNED
BY THE INSURED
. ALL VALUES ARE SUBJECT TO REVIEW BY UNDERWRITING.
NAME OF OWNER(S)
*
:
STREET ADDRESS
*
:
CITY
*
:
POSTAL CODE
*
:
PROVINCE
*
:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Québec
Saskatchewan
Yukon
BUSINESS PHONE NUMBER:
HOME PHONE NUMBER
*
:
FAX:
EMAIL ADDRESS
*
:
CLOSING DATE (if applicable):
OCCUPANT:
Owner
Rented
Vacant
NUMBER OF FAMILIES IN THE HOME:
DO YOU HAVE ANY TENANTS?
Yes
No
If Yes, how many?
Do they rent
a room?
or
an apartment?
Where is the room, or the apartment, located in the house?
IS THERE ANY BUSINESS OPERATION IN THE HOME?
Yes
No
If Yes, please explain:
HOME TYPE:
Detached
Semi-detached
Apartment
# units in building:
YEAR BUILT:
If over 25yrs, please indicate the year when the following have been updated:
Heating
Plumbing
Wiring
Roof
PRIMARY HEATING:
Gas
Oil
Woodstove
Other
If Oil, is the tank
Inside ?
Outside ?
Is the tank
Above Ground
Below Ground
Age of tank
SECONDARY HEATING:
Gas
Oil
Woodstove
Other
If Oil, is the tank
Inside ?
Outside ?
Is the tank
Above Ground
Below Ground
Age of tank
AMP SERVICE:
NUMBER OF STORIES:
SQUARE FOOTAGE OF ENTIRE HOUSE:
SQ. FOOTAGE OF BASEMENT:
SQ. FOOTAGE OF BASEMENT FINISHED:
SQ. FOOTAGE OF CRAWL SPACE:
EXTERIOR WALLS:
Wood Siding
Wood Shakes
Brick Veneer
Stone Veneer
Block
Vinyl Siding
Stucco on Frame
Aluminum Siding
Solid Stone
Solid Brick
Log
Other
If Other, please indicate:
ROOFING:
Asphalt Shingles
Wood Shakes
Wood Shingles
Slate
Tar & Gravel
Clay Tile
Copper
Rubber
Tin
Steel Roofing
FibreGlass
Other
If Other, please indicate:
GARAGE:
Attached
Detached
Built-In
Carport
Not Applicable
IS GARAGE
1 Car
2 Car
3 Car
4 Car
IS THERE A ROOM ABOVE THE GARAGE?
Yes
No
If Yes, how many square feet?
DO YOU HAVE A PORCH OR A DECK?
Yes
No
If Yes, construction type:
Concrete
Wood
Sq. footage of the porch or deck:
Is the porch or deck enclosed?
Yes
No
DO YOU HAVE A TENNIS COURT?
Yes
No
Pavement type:
Asphalt
Clay
Grass
DO YOU HAVE A SWIMMING POOL?
Yes
No
If Yes, is the pool
Above Ground
In Ground
Size of Pool:
NUMBER OF FULL (4-PIECE) BATHROOMS:
NUMBER OF FULL (3-PIECE) BATHROOMS:
NUMBER OF HALF (2-PIECE) BATHROOMS:
DO YOU HAVE A FIREPLACE?
Yes
No
If Yes:
Single
Double
Triple
Gas
CENTRAL AIR CONDITIONING:
Yes
No
If Yes, what type of ducts?
Heat ducts
Separate ducts
Using electric heat pump?
Yes
No
Whole house fan?
Yes
No
FLOORING FINISH TYPE(S):
hardwood
carpet
laminate
ceramic tile
vinyl
BUILT-INS
Central vacuum
Intercom system
Central burglar system
Central fire alarm system
Extra kitchen
Skylights
If Yes, how many?
Hot tub
Jacuzzi
Gazebo
Cabana
LIST ANY ADDITIONAL FEATURES:
LIST ANY ADDITIONAL UPGRADES:
FIRE PROTECTION
IS THERE A FIRE HYDRANT WITHIN 1000 FEET OF THE HOUSE?
Yes
No
THE NEAREST FIREHALL IS
KMs AWAY, LOCATED IN
INFORMATION TO DETERMINE POSSIBLE DISCOUNTS
IS THERE A MORTGAGE ON THE HOME?
Yes
No
If Yes, name and address of the mortgagee:
Amount of the mortgage:
DATE OF BIRTH:
SPOUSE DATE OF BIRTH:
HAVE YOU HAD ANY CLAIMS IN THE PAST 5 YEARS?
Yes
No
Date & Description:
List all CLAIMS, POTENTIAL CLAIMS or ACTIONS pending or brought against you or any employee in the last three years
HAVE YOU HAD PREVIOUS INSURANCE?
Yes
No
If Yes, indicate Company name:
Indicate policy number:
Expiry date:
SIGNATURE (ENTER YOUR NAME)
*
:
date signed
D
M
YEAR
