Name:
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
GTA Amateur Tour Member?	Yes    No
Have you ever had insurance cancelled or refused?	Yes    No
Do you currently insure your property?	Yes    No
Number of years prior insurance:
Expiry date with present insurer:	(dd/mm/yyyy)
What is your date of birth?	(dd/mm/yyyy)
	Property #1	Property #2
Property type:	Home Condominium Seasonal Residence Apartment	Home Condominium Seasonal Residence Apartment
Use:	Principal home Cottage (summer only) Cottage (year-round) Rented property Other	Principal home Cottage (summer only) Cottage (year-round) Rented property Other
Do you:	Own Rent	Own Rent
Year built:
If property over 20 years old, which of the following have been replaced?	Furnace Roof Wiring Plumbing	Furnace Roof Wiring Plumbing
Is property equipped with an alarm?	None Burglar only Fire only Fire and Burglar	None Burglar only Fire only Fire and Burglar
If yes, is alarm	Local only Monitored by company	Local only Monitored by company
Are you within 300 m of a hydrant?	Yes    No	Yes    No
Are you within 13 km of a firehall?	Yes    No	Yes    No
Discount Information
I am mortgage-free
I am a non-smoker
Amount of coverage required
Building:
Contents:
Liability:	$1,000,000 $2,000,000 $5,000,000	$1,000,000 $2,000,000 $5,000,000
Deductible:	$500 $1,000	$500 $1,000
Recent claims
#1:	Type: N/A Break-in Fire Jewellery lost Jewellery stolen Water damage Other Date: (mm/yyyy) Location involved: N/A Property #1 Property #2
#2:	Type: N/A Break-in Fire Jewellery lost Jewellery lstolen Water damage Other Date: (mm/yyyy) Location involved: N/A Property #1 Property #2
#3:	Type: N/A Break-in Fire Jewellery lost Jewellery lstolen Water damage Other Date: (mm/yyyy) Location involved: N/A Property #1 Property #2
Comments: