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Location Address :

Mailing Address :

Home Ph :

Cell Ph :

Effective Date :

Policy Type :
onetwo

If moved in last 3 years – previous address :

Policy Number :

Any Claims?:
YesNo

First Loss Payee :

Second Loss Payee :

Year Built :

Number Of Stories :

Total Square Footage :

Number Of Families :

Ground Floor Sq Footage:

Number of Rental Suites :

Total Square Footage :

Number Of Families :

Upper Level Sq Footage :

Intercom :

Total Square Footage :

Number Of Families :

Basement Finished :

Alarm System – Local or Monitored :

Full Washroom :

Swimming Pool :

Half Washroom :

Skylights :

Fireplaces – Gas or Wood Burning :

Garage Door Opener :

Sundecks :

Built-In Vacum:

Type Of Roof :

Jetted Bath Tub :

Type Of Heating :

Interior Flooring :

Garage – Built in or Attached :

Any rooms above garage :

Ceiling 8′ or 9′: :

Plumbing :

Exterior Finish :

Heating:

Earthquake ?:
YesNo

Roof:

Glass Policy ?:
YesNo

Hot Water Tank: