Parry Sound Insurance Brokers Ltd. - Quotation for Residential Homeowner

7 William Street, Unit #2
Parry Sound, Ontario
CANADA
P2A 1V2
Tel: (705) 746-2725
Fax: (705) 746-6420

Quotation for Residential Homeowner

If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: psinsure@zeuter.com
Important: Please be accurate in completing this form. Your quotation will be based on the information you give us today.
If these facts change, your rate will be subject to adjustment. Information requested below is used by this brokerage to develop a prospect profile
and may or may not be used in the pricing of any estimated policy premiums.

Personal Information

First Name:

Last Name:

E-Mail:

Address:

City/Town:

Province:

Postal Code:

Home Telephone:

Business Telephone:

Fax Number:

Occupation:

Current Policy Information

Insurance Company:

Policy Number:

Policy Expiry Date:

Amount of Insurance:

Property Description

Is the dwelling within 8km (5 miles) of a firehall? N/A Yes No

Is the dwelling within 300m (1000ft.) of a fire hydrant? N/A Yes No

Do you run a business from the premises? N/A Yes No

Number of families in dwelling:

Year of Construction:

If built over 15 years ago, indicate the year the following were last upgraded:

Electrical:

Plumbing:

Roofing:

Heating:

Number of Smoke Detectors:

Number of Deadbolts:

Is dwelling equipped with:

Centrally monitored burglar alarm? N/A Yes No

Centrally monitored fire alarm? N/A Yes No

Does the dwelling have an oil tank? N/A No Yes

Age: Years

Do you have a pet? N/A No Yes

Area of Main Floor:

If Other, specify:
If Other, specify:
If Other, specify:

Number of Bathrooms: N/A 2pc 3pc 4pc+
If you have bathrooms with more than 4 pieces please provide details:
(How many pieces?/ How many bathrooms?)

Number of Fireplaces: (Inside chimney) (Outside chimney)

Does the Dwelling include:

Garage? N/A No Yes

Number of Cars:

Finished Basement? N/A No Yes Living Space:

Rec. Room:

Sunroom? N/A No Yes Area:

Number of Stories:

Does the Sunroom have a Basement? N/A Yes No

Deck? N/A Yes No Area:

Porch (Ground area)? Porch #1

Area:

Porch #2

Area:

Inground Swimming Pool? N/A Yes No Area:

If Other, specify:

Above Ground Swimming Pool? N/A Yes No Area:

Finished Attic? N/A Yes No

Central Air Conditioning? N/A Yes No

Wood Burning Stove? N/A Yes No

Select Your Specialty Rooms from the following list:

Den (not converted bedroom) N/A Yes No

Family Room (in addition to a Living Room) N/A Yes No

Formal Dining Room (not dining area, dinette or breakfast nook) N/A Yes No

Large Foyer (over 70 sq. ft.) N/A Yes No

Laundry Room (over 70 sq. ft.) N/A Yes No

Library N/A Yes No

Office N/A Yes No

Recreation Room N/A Yes No

Study N/A Yes No

Sunroom N/A Yes No

Other (Specify):

Claims Information

Have you made any claims in the past five years? N/A Yes No

Description of Claims Amount of Loss

Optional Coverages

Personal Articles

You may wish to insure the items mentioned below for amounts in excess of the existing policy limits. Please state the total value of these items you wish to insure separately.

Fine Art:
Furs:
Jewellery:
Other:

Secondary/Seasonal Dwelling

Address:

Country:

Lot #:

Postal Code:

Is the dwelling within 8km (5 miles) of a firehall? N/A Yes No

Is the dwelling within 300m (1000 ft.) of a fire hydrant? N/A Yes No

Contents value:

Building Value:

If over $100,000, please fill in an additional Residential Request for Quotation and complete the Homeowners sections.

Please recheck to make sure you have supplied all information requested. Please make sure each section in filled, so that all your applicable discounts can be determined.

Parry Sound Insurance Brokers Ltd., 7 William Street, Unit #2, Parry Sound, Ontario, CANADA P2A 1V2
tel: (705) 746-2725 * fax: (705) 746-6420 * email: psinsure@zeuter.com

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Box 225, Parry Sound, Ontario, CANADA P2A 2X3 Tel/FAX (705)746-4625
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