Need Help? Contact Your Broker Information for Home Insurance Quotation Information For Home Quotation Information For Home Quotation What Broker are you working with?(Required)Please SelectCan't RecallCharlene DeLorenziCheryl-Tabor CampbellCourtney CarruthersCrissy McKayDonna RossEvan DegraziaJeff JonesJena CoullJenn LawrJose Canales CruzKaitlyn MorrisonKalya WilsonKofi AgboMark BraundNick GibsonName(s) On Title:First Name (On Title)Last Name (On Title) Add RemovePhone Number:(Required)Email:(Required) Preferred Method of Contact:(Required) Phone Email Risk Address:(Required) Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Date of Birth (1st Owner):(Required) MM slash DD slash YYYY Date of Birth (2nd Owner): MM slash DD slash YYYY Have You Moved in the Last 3 Years?(Required) Yes No Prior Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Gender:(Required) Occupation:(Required) Dwelling InformationYear Built:(Required) Foundation Type:(Required) Poured Concrete Wood Crawl Space Post Core Floor Dwelling Style:(Required) Detached Semi-Detatched Townhouse Mobile / Modular Seasonal Rented Dwelling Number of Stories:11.522.533.54+Total Square Footage of the Main Floor:(Required)Do you have a basement? Yes No Total Square Footage of Basement:(Required)Percentage of Basement Complete:(Required)Total Square Footage of Main Floor & Above:(Required) GarageGarage:(Required) Attached Detached None Age of Garage:(Required) 0-30 Years 30+ Years Size of Garage (Number of Vehicles):(Required)What is the main material on the exterior walls of the garage?(Required)AggregateAluminumAsbestosBrickBrick VeneerCedar SidingCementCement Fibre BoardCement Fibre Shingles Concrete Block/Masonry FrameFibreglassFire ResistiveFrame (Wood)LogLog SidingMasoniteMasonryMasonry Non-CombustibleMasonry VeneerMetal SidingMonocoqueNon-Fire Resistive ApartmentSteelStuccoVinyl SidingOther RoofYear of Roof:(Required) Roof Type:(Required)AshphaltMetalOther ElectricalElectrical Last Updated (Year):(Required)Percentage Updated:(Required)Amp Service:(Required)Type of Panel:(Required) Breakers Fuses Material of Electrical:(Required)CopperAluminumKnob & TubeMixUnknown PlumbingPlumbing Last Updated (Year):(Required) Percentage Updated:(Required)Material Type:(Required)Metal - CopperMetal - Cast IronMetal - LeadMetal - GalvanizedPlastic - OtherPlastic - PVCPlastic - ABSPlastic - PexPlastic - POLYBMixed - OtherMixed - Copper/ABSMixed - CopperPVCType of Water Heater:(Required) Hot Water Tank Tankless Water Heat Heat Pump Year of Hot Water Tank:(Required) HeatingYear of Furnace:(Required) Type of Heating:(Required)Central Furnace – GasCentral Furnace – OilCentral Furnace – PropaneCentral Furnace – WoodElectricHot Water/SteamCombination FurnaceCombination Furnace – (Add-on)Combination Furnace – Wood and ElectricityCombination Furnace – Wood and OilCombination Furnace – Oil and ElectricitySolid FuelSolid Fuel – PelletSolid Fuel – OilSolid Fuel – CoalSpace Heater – GasSpace Heater – ElectricWood Burning StoveFireplaceFireplace InsertSolarHeat PumpHeat Pump – OilOtherNoneAuxiliary Heating (Backup Heating System):(Required) Yes No Type of Auxiliary Heating:Central Furnace – GasCentral Furnace – OilCentral Furnace – PropaneCentral Furnace – WoodElectricHot Water/SteamCombination FurnaceCombination Furnace – (Add-on)Combination Furnace – Wood and ElectricityCombination Furnace – Wood and OilCombination Furnace – Oil and ElectricitySolid FuelSolid Fuel – PelletSolid Fuel – OilSolid Fuel – CoalSpace Heater – GasSpace Heater – ElectricWood Burning StoveFireplaceFireplace InsertSolarHeat PumpHeat Pump – OilOtherNoneNumber of Fireplaces:(Required)Any Wood Burning Stoves?(Required) Yes No Installed by a Certified Professional?(Required) Yes No Not Applicable Water & SepticSewer Backup Prevention:(Required) Sump Pump Sump Pump with Battery Backflow Valve Septic Field None Body of Water / Reservoir Within 100 Meters?(Required) Yes No House Hydrant Protected:(Required) Yes No Reverse Sloping Driveway:(Required) Yes No Distance to Closest Responding Firehall:(Required) Under 5k Over 5k Over 13k Automatic Main Water Shut Off?(Required) Yes No Number of Sensors:(Required) Mortgage InformationMortgage:(Required) Yes No Number of Mortgages:123Mortgage Lender:(Required) Second Mortgage Lender:(Required) Third Mortgage Lender:(Required) HousingWhat is the main material on the exterior walls of the house?(Required)AggregateAluminumAsbestosBrickBrick VeneerCedar SidingCementCement Fibre BoardCement Fibre Shingles Concrete Block/Masonry FrameFibreglassFire ResistiveFrame (Wood)LogLog SidingMasoniteMasonryMasonry Non-CombustibleMasonry VeneerMetal SidingMonocoqueNon-Fire Resistive ApartmentSteelStuccoVinyl SidingOtherOccupancy:(Required) Single Family Rental Suite Boarders Vacant Air BNB Number of Full Bathrooms:(Required)Number of Half Bathrooms:(Required)Do you have any Patio Decks?(Required) Yes No Square Footage of Deck:(Required)Deck Material:(Required) Build Quality:(Required) Basic Standard Upgrade Custom Additional Features (Check all that apply): Sauna (Wood) Sauna (Electric) Swimming Pool Solarium / Sunroom Solar Panels / Geothermal Hot Tub Additional Features (Other): CannabisCannabis Plants Grown:(Required) 0 1 2 3 4 5+ Underwriting InformationDo you currently have Property Insurance?(Required) Yes No Who is your current Property Insurance provider? Number of Years Residing at Residence:(Required)Number of Years of Continuous Property Insurance:(Required)Current Deductible:(Required)Current Liability Limit:(Required)Renewal Date / Closing Date:(Required) MM slash DD slash YYYY Any Claims in the Last 5 Years?(Required) Yes No Type of Claim:(Required) Payout ($):(Required)Any Major Renovations in the Past 5 Years?(Required) Yes No Describe Renovation Details:Farming Done on Premises?(Required) Yes No Describe Type of Farming:Increased Outbuilding Coverage Required?(Required) Yes No What Limit is Required? Home-Based Business?(Required) Yes No What Type of Business?(Required) Scheduled Items? Boat(s) Jewelery Vacation Trailer(s) Fine Art Other Total Value of Boat(s):Total Value of Jewelery:Total Value of Vacation Trailer(s):Total Value of Fine Art:Total Value of Other Scheduled Items:Describe Details of Scheduled Items:Is Your Property Over 1 Acre? Yes No Discount InformationDo you or anyone who resides in the home smoke cigarettes or cannabis?(Required) Yes No Monitored Security System?(Required) Yes No Do you currently have Auto Insurance?(Required) Yes No Auto Renewal Date:(Required) MM slash DD slash YYYY Auto Insurance Company:(Required) Privacy PolicyConsent:(Required) I agree to the privacy policy.As your broker, I am gathering this consent on behalf of the insurer who advises me that: In respect of this quotation, we may collect, use and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law. Do you, and on behalf of others listed, authorize us to collect, use and disclose to appropriate third parties, including your broker, this information solely relating to your personal property policy for the purposes necessary to assess the risk, determine a premium, investigate and settle claims, analyze business results and detect and prevent fraud? Additional Notes or InformationCommentsThis field is for validation purposes and should be left unchanged. Need Help? Contact Your Broker www.jonesins.com © Copyright 2022 Jones & Associates Insurance
