Name: Address: City: Province: Postal Code: Phone number: Email: Do you own your own home, own a condo unit or rent: Homeowner Condo Owner Renter Estimated replacement value of dwelling (homeowner only): Estimated replacement value of personal property: Policy deductible preferred: $1,000 $500 Liability amount requested: $2,000,000 $1,000,000 How many years have you consistently had a property policy in force: Number of claims in the past 10 years: How many years since last claim (if within 10 years): Do you smoke: YesNo Do you have a monitored alarm? (fire & burglary): YesNo Do you have a mortgage/secured line of credit on the property: YesNo What is your occupation: How many years since last time you moved: What is your age? (or oldest age of named insured person): Was your prior policy canceled for non payment: YesNo Was your policy lapsed for any other reason by the insurance company: YesNo What is the amount of jewelry required to be scheduled: Which insurance company has your current auto insurance: