Quotation ...
Personnal information
1-First name:
2-Family name:
3-Date of birth, Day Month Year
4-Sex: M F 5-Smoker: Yes No
6-Marital Status: Married Single Common law
7-Since what year have you had this marital status (Ex:1990)
8-Address: 9-Apartement:
10-City: 11-Postal Code :
12-Since what year have you been living at this address (Ex:1992)
13-E-mail:
14-Telephone(home): 15-Tel (work):
16-Occupation: 17-Fax:
18-Employer:
Claims
Enter your claims for the last six years, claimed or not, fire, theft, vandalism.
Date (DD/MM/YYYY) Type of claim
/ / TO CHOOSE Boat - all claims Broken glass - all claims Credit cards - all claims Sewer backup - building Sewer backup - contents Diverse Fire, lightning, explosion - building Fire, lightning, explosion - contents Responsability - bodily damage Responsability - material damage Windstrom, hail - building Windstrom, hail - contents Earthquake Vandalism - all claims Theft by force, silver, etc. Theft by force - diverse Theft by force - furs, jewelry Theft by force - electronic material No claims
Description
Residential information
19-Year that the building was built: 20-Residence : TO CHOOSE Home Owner Tenant Condominium Unit Owner Additional Seasonal In Construction
21-Value of the building : 22-Value of your personal property:
23-How many apartments are there in the building(single dwelling-1) ?
24-Construction : Wood - Brick Wood Resistant to fire Mobile Home Vinyl, etc. TO CHOOSE 25-Heating : Electric Central Combined Stove Integrated Radiator TO CHOOSE
26-Combustible : Electricity Oil Gas Others TO CHOOSE
27-Do you have any extra sources of heating (Fire place, wood burning stove, etc) Yes No
28-Is there anything commercial at your residence YesNo
29-Is there a fire hydrant within 300 feet of your residence YesNo
30-Is there a fire station within 5 km of your residence YesNo
31-Is there a fire station within 8 km of your residence YesNo
32-Do you have an alarm system ? No alarm system Fired connected Theft - local Theft - connected Fire & theft connected TO CHOOSE
33-Do you have a mortgage for the building ? YesNo
If yes which one ?
34-Would you like additional coverage fore fire, explosion, and smoke following an
earthquake ? YesNo
35-Do you have a pool ? YesNo
36-Do you want additional protection against sewer back-up ? YesNo
You can enter additional information that you judge to be of importance in insuring your home.
How to contact you ?
37-What is the best time to contact you? Day Night No specific time
38-Do you have insurance with us presently (other vehicles,house)? YesNo
39-How would you like an agent to contact you ? By telephone By e-mail
40-The insurance is require for what date ? Day Month Year
41-This quotation is for a ? renewal new purchase
42-How long have you been mentioned on an insurance contract (years) ?
43-Who is your current insurer(if you don't have one mark:none) ?
44-Have you ever been refused an insurance contract or renewal ? Yes No
45-What is your actual premium ?
46- How did you discover our internet site ? TO CHOOSE Search engin(ex: Yahoo) Yellow pages Yellow pages internet Friend - reference Via our advertisements of setting on standby Via our advertisements by e-mail
47-Would you accept that the insurance company verify your credit score to establish a better premium? Yes No