Contact Information:

Name:
Street Address:
City:
Postal Code:
Phone Number:
Fax Number:
E-mail:

Insurance Information:

Have you had any claims in the past 5 years?  Yes No 

Home Details:

My Home also includes:

My home was built in the year: 

How many deadbolts do you have? 

Do you have an alarm system?   Yes No 

Is your home fire hydrant protected? Yes No 
If not, how far from nearest fire station?  kilometers

How many smoke detectors are in your home? 

What is the approximate value of significant personal articles:

Is there watercraft on your present  policy? Yes No 

How would you prefer we contact you?

  E-mail    Phone    Fax    Mail 

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