Name
	Address
	City
	Postal Code			-
	Phone			- -
	Fax			- -
	Email
1.	Do you			Own		Rent
2.	Type of Dwelling
		Apartment		Townhouse		Basement Suite		House
		Mobile Home
3.	Building Information
		Frame		Fire Resistive / Concrete				More than 6 suites
	Fire hydrant within 300 Meters
		Yes		No
	Firehall within 8 Kms
		Yes		No
4.	Is your suite on the 1st floor?
		Yes		No
5.	Type of coverage
		Basic		All Risk		Both
6.	Age Group ( Oldest member on title )
		Under 45		45 - 49		50 - 54			55 - 59
		60 - 64		65 +
7.	Do you have a Burglar Alarm?
		Yes		No
	If Yes, is it:
		Local		Monitored
8.	Do you have a Fire Alarm?
		Yes		No
	If Yes, is it:
		Local		Monitored
9.	Have you moved in the last 6 years?
		Yes		No
10.	Have you been insured for at least 3 years continuously (not including ICBC)?
		Yes		No
	If yes, how many years have you had habitational insurance?
	Indicate # of Years
11.	Have you had any claims in the past (excluding ICBC)?
		3 Years		5 Years		7 Years			No
12.	Amount of insurance required (minimum $40,000):
	$
13.	Optional Coverages Required:
	Earthquake			Yes		No			Both
	Optional Glass Policy			Yes		No			Both
	Increased Liability			2 Million		3 Million *			5 Million *
	Other (please list what limit required):				$
	* On company's approval
	Responses to all questions required for an accurate quote.