UXBRIDGE
33 Toronto St. N.
Box #1540
Uxbridge, ON L9P 1N7
905-852-9191 or
1-888-354-6444
Fax: 905-852-6088

MOUNT ALBERT
19139 Centre Street
Box 130
Mount Albert, ON L0G1M0
905-473-2797 or
1-888-301-5222
Fax: 905-473-5499

Property Insurance Quote

Should you not wish to complete the following form, please provide a day time phone number so that we may contact you by phone.

Contact Information:
Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
How do you wish to be contacted:

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:
Use:
Do you:	Own Rent	N/A Own Rent
Year Built:
If property over 20 years old, which of the following have been replaced or updated:	Furnace Roof Wiring Plumbing	Furnace Roof Wiring Plumbing

Auxiliary Heat:	Wood stove Fireplace Gas Fireplace	Wood stove Fireplace Gas Fireplace
Is property equipped with alarm:	Yes No	N/A Yes No
If yes, is your alarm:	Local Monitored	N/A Local Monitored
Are you within 300 m of a hydrant:	Yes No	N/A Yes No
Are you over 5km and within 13 km of a fire hall:	Yes No	N/A Yes No

Discount Information:
I am mortgage free:	Yes No
I am a non-smoker:	Yes No

Amount of coverage needed:	**subject to a current property evaluation.
Building:
Contents:
Liability:	$500,000 $1,000,000 $2,000,000	N/A $500,000 $1,000,000 $2,000,000
Deductible:	$500 $1,000	$500 $1,000

Recent Claims:	Type	Date (mm/yyyy)	Location:
	1.
	2.
	3.


If you require any coverage on boats, jewellery or a home based business, add your request in the comments section below.
Comments:

Please copy the following text into the textbox below.