Get a Quote – Home – Cluett Insurance

Have you ever had any cancellations, claims, or gaps in insurance? *

Yes

No

Email *

Name *

Address *

Address

City

Province

Postal

Phone *

Effective Date *

Date of Birth *

Do you agree with the following consent statement? *

Yes

No

As your broker, I am gathering this consent on behalf of the insurer who advises me that: in respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may collect,use and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law and in accordance with our privacy policies.

Do you, and on behalf of others listed, authorize use to collect, use and disclose to appropriate third parties, including your broker, this information solely relating to your personal property policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settile claims, analyze business results and detect and prevent fraud?

Insured

Years of continuous home insurance *

Date since continuously insured on home or tenant policy? *

Current Insurer *

Do you operate a business out of your home? *

Yes

No

Home-Based Business Details

Please provide details on business. *

General

Distance to the nearest fire hydrant? *

Distance to the nearest fire hall? *

Do you have a mortgage? *

Yes

No

Building Information

Square footage excluding the basement? *

Year built? *

Style of Home? *

Primary Exterior Siding *

Bathrooms

Number of Full Bathrooms *

Number of Half Bathrooms *

Basement

Finished, Partially Finished, or Unfinished Basement? *

Finished

Partially Finished

Unfinished

Square footage? *

Do you have a garage? *

Yes

No

Garage

Is it Attached or Detached? *

Attached

Detached

Square footage? *

Year built? *

Additional Structures

Are there any additional structures on the property? i.e. shed, garage, swimming pool, etc. *

Yes

No

If yes, please provide year built, square footage, construction type, exterior siding, and roof material for ALL additional structures. *

Dates / Details

Occupied Since? *

Primary Heating Details? *

If Furnace - Oil, what is oil tank year?

If Furnace - Oil, where is the oil tank located?

Inside

Outside

If Furnace - Oil, what is the oil tank construction type?

Double-walled Steel

Fibreglass

Other

Year the heating was last updated? *

Chimney Type? *

Do you have a secondary heat source? *

Yes

No

Secondary Heating Details

Year the heating was last updated? *

Chimney Type? *

Metal

Brick

None

Roofing Details

Year that the Dwelling's roof was last updated? *

Roof Material *

Plumbing Details

Year that the plumbing was last updated? *

Plumbing Type? *

Septic System? *

Yes

No

Do you have a Hot Water Tank? *

Yes

No

Hot Water Tank

Year that the Hot Water tank was last updated? *

Electrical Details

Year that the Electrical Service was last updated? *

Type of wiring? *

Service? *

60 AMP

100 AMP

200 AMP

Year that the panel was last updated? *

Type of panel? *

Claims

Number of claims on any property owned within the last 6 years? *

Additional Information

Any additional information?

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