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Car
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Gold Private Client
Get A Quote
Home Insurance Quote
Home Insurance Quote
Step
1
of
4
25%
Full Name
*
Date of Birth
*
Current Address
*
City
*
Province
*
Postal Code
*
Preferred method of contact
*
PREFERRED METHOD OF CONTACT*
Email
Phone
Phone
*
Email Address
WHAT HAS BROUGHT YOU TO US TODAY?*
*
WHAT HAS BROUGHT YOU TO US TODAY?*
I am an existing client
Family or Friend
Referred by/am a Medallion member
Online Advertising
I am a group member
Social Media
Google
Referred by / am a Magenta client
Spotify/Radio
Other
Office location and/ or your broker's name:
Referred by (full name):
If other, how?
*
Group Type:
PLEASE SELECT GROUP TYPE:
Lions Club Member
Police / Law Enforcement
Firefighter
Medical First Responder
Conservation Officer
Other First Responder
Kitchener Wilmot Hydro
Bluewater Power
Johnson Controls
Noranco
Holliswealth
Justice of the Peace
OACCPP
Home Details
Address of Purchased Home
*
Year Built
Square Footage (not including garage or basement)
Style of Home
Number of Full Bathrooms
NUMBER OF FULL BATHROOMS
1
2
3
4+
Number of Half Bathrooms
NUMBER OF HALF BATHROOMS
1
2
3
4+
Type of Plumbing
TYPE OF PLUMBING
Copper
Plastic
Cast Iron
PEX
When was your plumbing last replaced?
Type of Heat
Age of Furnace
Type of wiring
TYPE OF WIRING
Breakers
Fuses
Copper
Aluminum
Other
Hydro (AMP)
HYDRO (AMP)
100 AMP
200 AMP
Exterior of Home
MAJORITY OF EXTERIOR OF HOME
Siding
Brick
Stucco
Other
Type of Roof
TYPE OF ROOF
Steel
Asphalt
Other
When was your roof last replaced?
Size of Deck
Size of Porch
Basement size (of finished area)
How far are you located from the closest fire hall?
Do you have a fire hydrant within 1000 ft of your home?
IS THERE A FIRE HYDRANT WITHIN 1000FT OF HOME
No
Yes
Does anyone in your house smoke?
SMOKERS IN HOUSE
No
Yes
Do you have a sump pump?
SUMP PUMP
No
Yes
Do you have battery back up?
BATTERY BACK UP (ON SUMP PUMP)
No
Yes
Backwater valve
BACKWATER VALVE
No
Yes
Garage
Type of Garage
TYPE OF GARAGE
Attached
Detached
Size of Garage
Do you have a mortgage?
DO YOU HAVE A MORTGAGE?
Yes
No
Any claims in the last 5 years?
ANY CLAIMS MADE IN THE PAST 5 YEARS
No
Yes
Type of Claim
TYPE OF CLAIM
Sewer Back Up
Fire
Theft
Other
Year Claim Made
Month Claim Made
MONTH CLAIM MADE
January
February
March
April
May
June
July
August
September
October
November
December
How long have you continuously been insured for home insurance?
Start date of your next policy (MM/DD/YYYY)
*
Preferred Deductible
PREFERRED DEDUCTIBLE
$1,000
$2,500
$5,000
CAPTCHA
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Name
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