Cabinet en assurance de dommages
514-429-3127
1-844-739-3127
info@assuranceconfiance.ca
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If you are unsure of a question, answer to the best of your knowledge
Step 1 of 4
25%
Number of owner
1
2
Owner # 1
First name:
Last name:
date of birth:
Street number:
Apartment numbert:
Street:
City:
Postal code:
Province :
Since when have you lived at this address?
Email:
Work phone:
Home phone:
Cellphone:
Preferred contact time:
Day
Night
Weekend
Preferred contact number
Home phone
Work phone
Cell phone
Gender:
Male
Female
Marital status:
Married
Single
Widowed
Divorced
Common-law
Levels of education attained:
High school / Professional / Vocational diploma (DEP)
College / Technical
University
Other
Occupation ?
Private sector employee
Federal government employee
Provincial government employee
Municipal government
Para-public sector employee
Student
Unemployed
Homemaker
Retired
Sole proprietor
Business owner
Other
Employment field:
Employment:
Employer:
Send me my quotes via text message (sms):
No
Yes
Owner # 2
First name:
Last name:
date of birth:
Street number:
Apartment number:
Street:
City :
Postal code:
Province :
Since when have you lived at this address?
Email:
Work phone:
Home phone:
Cellphone:
Preferred contact time:
Day
Night
Weekend
Preferred contact number
Home phone
Work phone
Cell phone
Gender:
Male
Female
Marital status:
Married
Single
Widowed
Divorced
Common-law
Levels of education attained:
High school / Professional / Vocational diploma (DEP)
College / Technical
University
Other
Occupation ?
Private sector employee
Federal government employee
Provincial government employee
Municipal government
Para-public sector employee
Student
Unemployed
Homemaker
Retired
Sole proprietor
Business owner
Other
Employment field:
Employment:
Employer:
Send me my quotes via text message (sms):
No
Yes
Informations
The reason for requesting a quote:
Renewing insurance
Buying a vehicle
Planning to buy vehicle
How did you hear about Assurance Confiance?
Reference friend / family
Website
Social media
Policy effective date:
Car insurance renewal date (if applicable):
Current insurer:
Current annual premium:
How many years in total you ensured without interruption?
Duration with insurers:
Have you ever declared bankruptcy?
No
Yes
Are you released?
Yes
No
In the past 10 years, have you or anyone living with you been convicted of a criminal offence?
Yes
No
If so, explain why:
Do you allow access to your credit rating and accident history, this will not affect your case?
Yes
No
Is the building subject to any zoning by-laws?
Yes
No
If so, explain what is or the zoning by-laws?
How many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?
None
1
2
3
More than 3
If so, expand the reason:
To the best of your knowledge, has the residence sustained water damage in the last 5 years?
Yes
No
If so, provide details:
Has your current insurer applied any limitations or special conditions to your insurance policy?
Yes
No
If so, provide details:
Have you filed any claims in the last 10 years?
Any
1
2
3
4
5
More than 5
Detailing the claim: #1:
Date :
Approximate amount:
Detailing the claim#2:
Date :
Approximate amount:
Detailing the claim #3:
Date:
Approximate amount:
Detailing the claim #4:
Date :
Approximate amount:
Detailing the claim #5:
Date:
Approximate amount:
detailing the claim that was not mentionned in the above 5:
Date :
Approximate amount:
Residence:
Residence type:
Primary residence
Three season Cottage/Chalet
Four season Cottage/Chalet
Rented ground
Other
Are all members of the household non-smokers?
No
Yes
Do you have animals at home?
Yes
No
What are your animals?
Distance from the nearest fire hydrant:
Less than 1000 ft / 300m
More than 1000 ft / 300m
Distance from the nearest fire hall:
Until 8 km / 5 mi
Between 8 km / 5 mi and 13 km / 8 mi
More than 13 km / 8 mi
Does the building owner live at this address?
Yes
No
Exterior cladding:
Brick facing
Vinyl siding
Stone masonry
Maçonnerie
Bois
Metal
Stucco
Building structure:
Detached single house
Semi-detached house
Apartment
Condominium
Rowhouse
Side by side duplex
Duplex
Townhouse
Year built:
Number of units in the building:
Roof shape:
Flat roof
Sloping
Roof material:
Asphalt shingles
Pre-painted metal
Metal
Membrane
Multi-layer with gravel
Multi-layer without gravel
Wood shakes
What special features apply to your roof?
Dormers
Skylights
Slopped roof gutters
Do you have a garage or a shelter of automobiles?
Yes
No
What is the type of your garage or shelter of automobiles?
Shelter
Adjoining the house- covering the brick garage / stones
Adjoining the house- coating the garage other than bricks / stones
Occupies part of the house
Occupies part of the basement
How many cars can your garage or shelter of automobiles contain?
Do you have a thermal pump?
Yes
No
Are there any commercial or business activities in the building (operated or not by you)?
Yes
No
If so, provide details:
Are more than 50% of main rooms finished wood or ceramic flooring?
Yes
No
Electric panel type:
With breakers
With Fuses
Primary heating source:
Electric
Natural gas
Oil
Propane
Hybrid Furnace
Water or steam
Heat
Geothermal
Auxiliary heating source:
Wood-burning stove
Pellet stove
Wood fireplace
Propane fireplace or stove
Gas fireplace
Solid fuel
Hybrid Furnace
None
Burglar alarm:
Local
Centrally
None
Fire alarm:
Local
Centrally
None
Water detection alarm?
Local
Centrally
None
Do you have a pool?
Yes
No
What type of your pool?
In-ground
Above-ground
Semi-in ground
Year of installation:
Do you have a spa?
Yes
No
What type your spa?
In-ground
Above-ground
Semi-in ground
Year of installation:
Does the residence is under construction?
Yes
No
Does the residence is currently under major renovation?
Yes
No
Do you rent this residence?
Yes
No
Term rental (if applicable):
Short term
Long term
Does the residence is vacant?
Yes
No
Number of Creditors:
None
1
2
3 or more
Who is the creditors ?
Building value (also known as 'Replacement Cost') shown on your current policy:
Dimensions of the house:
Number of floors excluding basement:
Finished basement?
No
25%
50%
75%
100%
Foundation Type:
Concrete
Bloc
Stone
Prevention equipment:
Backwater valve
Sump pump
Age of the water heater:
If you have made renovations, please specify the year
Roof:
Plumbing
Heating system:
Electrical system:
Are corrections requested by a previous insurer has not been done?
Yes
No
If so, provide details:
Guarantees
Desired deductible:
$300
$500
$1000
Legal liability coverage:
$1 000 000
$2 000 000
Building insurance amount:
Do you currently have insurance coverage for water damage – Above ground water?
Yes
No
For what amount?
Do you currently have insurance coverage for water damage – Ground water and sewers?
Yes
No
For what amount?:
Do you currently protected from damage caused by water entry?
Yes
No
For what amount?
What other warranty you want?
Additional notes: