Home Evaluation Form

First Name *

Last Name *

Phone Number *

E-mail address *

Policy Number (if available)

Full Address of Property for Home Evaluation *

Please fill out the questions below and click the Submit button when finished. You can also save your partial entires and return to this form at a later date by creating a login identification and password at the bottom of this page.

Square Footage of Total
Living Area (excluding basement) *

Year Property Built *

Type of Structure *

Exterior Siding *

Vinyl siding	Stucco
Wood siding	Other (please specify) Other (please specify)

Roof Material *

Number of Bathrooms *

Full
Half

Does the property have a garage? *

If yes, is the garage attached or detached?

Attached

Detached

If you have a garage, how
many cars is the garage?

1 car	2 cars
3 cars	4 cars

Is there a bonus room
above the garage? *

No

Yes, Estimated square feet is Yes, Estimated square feet is

Is the basement developed? *

Is your basement a walk-out? *

How many kitchens are there? *

Does the property have a free standing wood burning stove?

Do you rent a room or suite in your house?

Do you have a home based business? If so, please specify (e.g. accounting/dayhome/music lessons etc)

No	Yes, please specify Yes, please specify

Do you have any of the following items you wish to schedule:

Jewellery

Bicycles over $1,000

Hearing Aids

Boat & Trailer

Do you currently have a mortgage on your property? *

Does the property currently
have an alarm system? *

If yes, is it locally or centrally monitored?

Local

Central

Does the property have
water sensors? *

How many years have you
lived at this current location? *

How many continuous years have
you had property insurance for? *

Have you had any property claims in the
last 10 years? If yes, please indicate the
date (MM/YYYY) and type of claim. *

No	Yes, please specify date (MM/YYYY) and type of claim Yes, please specify date (MM/YYYY) and type of claim

Do you have a sump pump with a backup power supply? *

No	Yes, Date of installation (MM/YY) Yes, Date of installation (MM/YY)

Do you have a back water valve? *

No	Yes, Date of installation (MM/YY) Yes, Date of installation (MM/YY)

Is your hot water heater tankless? *

What year was your
furnace last replaced?

What year was your
roof last replaced?

What year was your hot water
tank last replaced?

Please provide the following for each named insured

Full Name *

Date of Birth (MM/DD/YYYY) *

Occupation *

Employer

Full Name

Date of Birth (MM/DD/YYYY)

Occupation

Employer

Any additional comments/remarks?

If your house was built BEFORE 2005, please answer the following questions on Type of Plumbing, Wiring & Electrical Service. Otherwise, you can skip this section.

Type of Plumbing

Copper

Plastic

Galvanized

Poly-B

Type of Electrical Wiring

Copper

Aluminum

Type of Electrical Service

Breaker Box

Fuses

How Many Amps is the electrical?

60

100

over 100

Year the Electrical Wiring
was upgraded or replaced.

Combining your Auto insurance with Home Insurance can give you SIGNIFICANT savings. Please enter your auto information below and we will be glad to also provide you a quote on your Auto insurance.

Gender

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Use

Pleasure

Driving to and from work

Annual Kilometres Driven

Number of One Way Kilometres To Work

Formatted Text

Form Login Account (optional)

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Asphalt Shingles	Clay Tile
Wood Shingle/Shakes	Cedar Shakes
Concrete Tile	Other (please specify) Other (please specify)