Please enter the information for the resident who will be the policyholder first.
This is usually the owner or lessee of the home.
NOTE: USE TAB TO FOLLOW FIELD SEQUENCE

Name
Street Address
Address (cont.)
City	Province
Postal Code	Country
Work Phone	Home Phone
E-mail	URL
What type of home insurance do you need?*                                               Home owner Condominium unit owner Tenant Cottage/Seasonal Residence What is the Date of Birth of the eldest homeowner?                                           Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Year 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908  What is your Date of Birth?                                                                              Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Year 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908
Insurance Information: Have you had a property insurance policy in the past 5 years?                               Please choose Yes No If No! What reason best describes why you are not presently insured?                  Please choose Moving out of parents home First time home buyer Other How long have you had this property insurance policy without interruption?           Please choose 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years or more
How many property insurance claims have you had in the last 5 years?                  Please Choose No claims 1 2 3 or more How many years has it been since your last property claim?                                   Please Choose Less than 1 year 1-2 years 2-3 years 3-4 years 4-5 years

In the past 5 years, have you had a property insurance policy cancelled by an insurance company OR has an insurer ever refused to insure this residence?            Please Choose No Yes

What was the reason for this policy cancellation or insurance refusal?                     Please choose Property value too high Age of the property Coverage needs changed Broker lost contract with insurer Vacant property Home business Roomers or boarders Postal code restrictions Other

Do you operate a home-based business** from your property?                                 Please Choose No Yes How many mortgages do you have on your residence?                                            Please Choose No mortgage 1 2 More than 2

Property information:

In what year was your residence built?                                                                    Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894 1893 1892 1891 1890 1889 1888 1887 1886 1885 1884 1883 1882 1881 1880 1879 1878 1877 1876 1875 1874 1873 1872 1871 1870 1869 1868 1867 1866 1865 1864 1863 1862 1861 1860 1859 1858 1857 1856 1855 1854 1853 1852 1851 1850 1849 1848 1847 1846 1845 1844 1843 1842 1841 1840 1839 1838 Has the roof of your property been replaced in the last 20 years?                            Yes No How is your residence currently occupied?                                    You and your family You and an additional family You and two or more families Property under construction/major renovations Vacant

Describe the residence:                                                                                          Detached Semi-detached Townhouse Row house Duplex Triplex Commercial property Farm Other What is the construction type*** of the residence?                                              Please Choose Solid brick (2 or 3 brick rows) Concrete block/stone Fire resistive concrete Brick veneer (only 1 row) Wood, vinyl, metal or stucco Log home Other

Do you know the replacement value**** (not market value) of your residence?   Please choose Yes No  If Yes! What is the replacement value of your residence?                                    What is the replacement value of your personal property?                                    Please choose $30,000 $31,000 $32,000 $33,000 $34,000 $35,000 $36,000 $37,000 $38,000 $39,000 $40,000 $41,000 $42,000 $43,000 $44,000 $45,000 $46,000 $47,000 $48,000 $49,000 $50,000 $55,000 $60,000 $65,000 $70,000 $75,000 $80,000 $85,000 or more

What is the total square footage of your home (including any finished basement)?      How many room-mates, roomers or boarders do you have?                                   Please Choose 0 1 2 3 4 or more

Heating Information: What is the primary method of heating***** in the residence?                              Please Choose Gas Oil Electric Propane Solar Wood Hot water/steam Other If oil, Is the tank less than 20 years old?   Please Choose Yes No             Where is the tank located?    Please Choose Inside Outside What additional heating do you use to heat your residence?                                  Please Choose Not applicable Certified wood or pellet stove Uncertified wood or pellet stove Fireplace insert Space heater Gas fireplace Wood-burning fireplace Other If wood stove or fireplace: How many cords of wood you use per year?                  Please select Less than 1 1 2 3 or more

How close to your home is the nearest fire hydrant?                                                0 - 100 m 101 - 200 m 201 - 300 m 301 - 400 m 401 - 500 m 501 - 600 m 601 - 700 m 701 - 800 m 801 - 900 m 901 - 1000 m More than 1000 m How close to your home is the nearest fire hall?                                                       Please Select Within a kilometer (1000 m) 2 km 3 km 4 km 5 km 6 km 7 km 8 km 9 km 10 km 11 km 12 km 13 km 14 km 15 km 16 km 17 km 18 km 19 km 20 km 21 km 22 km 23 km 24 km 25 km More than 25 km away

Discounts:
Some companies offer a discount on your home insurance policy if you get, or currently have, an auto policy with them. Would you like your home insurance quote to show this discount?	Please choose Yes No

Do you have any alarm systems in your home?                       Please choose Yes No What type of burglar alarm do you have?                               Please choose Local Monitored None What type of fire alarm do you have?                                     Please choose Local Monitored None Are all exterior doors equipped with deadbolt locks?             Please choose Yes No

When do you want the new Home Insurance to begin?    Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Year 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908