KW Insurance Brokers O/B 1216592 Ontario Ltd. (Reg. Insurance Broker - Auto Home Tenant Boat Life Disability Illness Retirement)

^*Please note:
This is a homeowners insurance quote form.

Looking for Tenant/Renter or Condominium quotes?

This form is also available in pdf format if you prefer not to complete the quote form online.

*REQUIRED INFORMATION

Contact Information

^*Name:

^*Telephone: (H) (W)

^*City:

Prov: ^*Postal Code: ^*Email:

^*Mortgage: Yes No
If yes, please check all that apply:
1st 2nd 3rd

^*Your Birth Date: (dd/mm/yy)
Spouse Birth Date: (dd/mm/yy)
Are you a smoker? Yes No
Is your spouse a smoker? Yes No

Location of Property: Same as above: Yes
If not, please enter address below:

^*Year Built:
^*Square Footage: (Living area)
Finished Basement: Yes No
If yes? Square Footage is:

Property Details:

Occupancy:
Primary Secondary Seasonal Rental

^*Construction Type:
Frame/Stucco Brick Veneer Vinyl/Aluminum Siding Double Brick Stone

Roof Type:
Asphalt Shingles - Year last replaced: Other

^*Structure Type:
Detached Semi Detached Townhouse Mobile Home Duplex Triplex

Number of Bathrooms:
4 PCS 3 PCS 2 PCS

Heating:

Furnace (Primary): Yes No
^*Furnace Type: Gas Electric Oil
^*If Oil was selected,
age of oil tank: years
Tank location: Inside Outside

Auxilary: ^*Please check all that apply.
Woodstove:     Yes   Wood Gas Electric
Space Heater: Yes
Electric:            Yes
Fireplace:         Yes   Gas   Wood Electric
^*Number of fireplaces if more than 1:
Fireplace Insert:    Yes   No

Central Air: Yes No
Central Vac: Yes No

Electrical Service:
Amp 60 100 100+
Wiring: Copper Aluminum Knob & Tube Unsure

Parking:
Garage Attached: Yes No Size: 1, 2 or 3 cars
Carport Size: 1 or 2 cars
None

Swimming Pool:
Above Ground Inground
Size: x Vinyl liner Concrete

Security Systems: Yes No Local Monitored
Type: ^*Please check all that apply.
Fire Burglar Sprinklers Smoke Detectors Other Security

Please check which are present in your home:
Skylights Wet Bar Hot Tub Jacuzzi

Insurance Details:

Present Insurer:
Name

Expiry Date: (dd/mm/yy)
Number of Years:

If you have no insurance at this time, have you ever had insurance? Yes No
^*If yes, please enter your previous insurance details below:
Name Policy Number:

^*Claims in the last 5 years? Yes No
If yes, how many:
Are any of the above within the last three years?
Yes No

Approx. dates/type of claims in the last 3 years:

Current Policy Coverages:
Dwelling: $ Detached Private Structures: $
Liability: $ Personal Property: $

Special Enhancement Endorsement:

*Please check all that are required

Books/tools/instruments pertaining to a business
Securities
Money or Bullion
Garden Type Tractors
Watercraft
Animals, birds and fish

Jewellery
Numismatic Property
Stamps and Philatelic Property
Silverware etc.
Bicycle
Collectibles

Additional Information:

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KW Insurance Brokers O/B 1216592 ON LTD 501 Krug St. (Krug St. Plaza), Kitchener, ON N2B 1L3 Telephone: (519) 744-4190 Fax: (519) 744-7664 Website: www.kwbroker.ca