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Home Questionnaire

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Homeowners Questionnaire
This home questionnaire should take 5-10 minutes to complete. The information you provide will allow us to properly review your coverage needs and provide you with the most accurate estimate tailored specifically to your own individual needs.
Which broker are you working with?*
Policy Holder Information
Name*
First Last
Date of birth*
MM slash DD slash YYYY
Occupation
Phone number*
Phone type*
- Home
- Mobile
- Work
Mailing address
Street Address
Email address
Prior address (if moved in past 3 years)
Street Address
Is there a second name on title for this property?*
- Yes
- No
Additional Policy Holder Information
Name
First Last
Date of birth
MM slash DD slash YYYY
Occupation
Phone number
Phone type
- Home
- Mobile
- Work
Email address
Prior address (if moved in past 3 years)
Street Address

Basic Property Details
Is your mailing address the same as your property address?*
- Yes
- No (Provide address below)
Property address*
Street Address Postal Code
Occupied since*
MM slash DD slash YYYY

What day did you move into this location?
Total Number of Families Living in Home*
Type of home*
Style of home*
Square footage*
Year built*
Do you have a full basement?*
Percent complete?
Exterior finish*
- Aluminum Siding
- Brick Veneer
- Cement Fiber Siding (Hardie Board)
- Log
- Stone Veneer
- Stucco
- Vinyl Siding
- Wood Siding
- Other
Garage/carport*
Is your home equipped with any special or unique features we need to be aware of?
Kitchen / Bathrooms
Number of kitchens*
Number of full bathrooms*
Number of half bathrooms*
Please indicate if your home is equipped with any of the following:
- Monitored Burglar Alarm
- Monitored Fire Alarm
- Monitored Leak Detection - Water Heater
- Monitored Temperature Alarm
- Monitored Water/Flood Alarm
- Swimming Pool
- Solar Panels
Do they provide power back to the grid?
Are they owned or leased?
Value of panels?

Updates
Insurance companies require confirmation that homes undergo regular maintenance.
Roof type*
Other roof type
Year of last roof update*
Primary heating type*
Auxiliary heating type
Year of heating update*
Does the home have a free standing wood stove or pellet stove.*
Plumbing type*
- ABS
- Copper
- Galvanized
- Iron
- Lead
- Pex
- Polyethylene (Poly-B)
- PVC
- Other
Year of last plumbing update*
Type of water heater*
Year water heater last replaced*
Type of wiring*
- Aluminum
- Copper
- Knob & Tube
- Unknown
Electrical amperage*
Panel type*
Year of last electrical update*

Additional & Optional Coverages
What limit of sewer back-up coverage do you require?*
We recommend that you carry a limit that is high enough to clean and sanitize your basement and replace your furnace, electrical, any basement development, and contents in the event of a serious sewer backup claim
Do you require coverage for overland water damage?*
Covers losses from the sudden accumulation or run off of surface water – including torrential rainfall as well as overflow from fresh water rivers and lakes
Is your home equipped with a sewer back flow valve?*
A type of check valve in a drainage pipe where the reversal of water flow causes the valve to close, thereby cutting off the water flowing back up through the pipe, also known as backflow valve.
Is your home equipped with a sump pump?*
A sump pump is a mechanical pump used to remove water that has accumulated in a sump pit. The water may enter the sump pit through drains funneling into the pit, or it may enter because of rain or because of natural ground water if the basement is below the water table level.
Does your sump pump have an auxiliary power Supply?*
Special Limits
Please check if any of the following apply to you (check all that apply)
- I own jewellery, watches, or furs with a total value over $5,000
- I own books or computers for business only valued over $5,000
- I own a collection (stamps, coins, wine, artwork) valued over $5,000
- I own garden equipment / lawnmowers valued over $10,000
- I own tools for professional use (ex: carpentry)
- I own a bicycle valued over $1,000
- I own a boat over 25HP or over 26ft in length
- I own art valued over $15,000
If you selected any of the above please describe the item(s):
Do you have a son/daughter attending school away from home?*
Value of possessions with them:
State the value of any spare auto parts you have stored.

Miscellaneous Info
Are you a smoker?*
Do you or are you planning to grow cannabis on the premises?*
Do you rent the property or a portion of as a short term rental such as Airbnb*
Is there a mortgage on the property?*
Have you had home/condo/tenants insurance before?*
Current insurance company name & policy number
Number of years of insurance history?
Have there been any claims made in past 5 years?*
If claims have been made, please describe them
Do you operate a home based business?*
Please describe your home based business, if applicable
Do you require a life insurance quote?*
Additional comments/information
Comments
This field is for validation purposes and should be left unchanged.

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