OWNER

If you are unsure of a question, answer to the best of your knowledge

Step 1 of 4

25%

Number of owner
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:
Preferred contact number
Gender:
Marital status:
Levels of education attained:
Occupation ?
Employment field:
Employment:
Employer:
Send me my quotes via text message (sms):
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:
Preferred contact number
Gender:
Marital status:
Levels of education attained:
Occupation ?
Employment field:
Employment:
Employer:
Send me my quotes via text message (sms):

Informations
The reason for requesting a quote:
How did you hear about Assurance Confiance?
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?
Are you released?
In the past 10 years, have you or anyone living with you been convicted of a criminal offence?
If so, explain why:
Do you allow access to your credit rating and accident history, this will not affect your case?
Is the building subject to any zoning by-laws?
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?
If so, expand the reason:
To the best of your knowledge, has the residence sustained water damage in the last 5 years?
If so, provide details:
Has your current insurer applied any limitations or special conditions to your insurance policy?
If so, provide details:
Have you filed any claims in the last 10 years?
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:
Are all members of the household non-smokers?
Do you have animals at home?
What are your animals?
Distance from the nearest fire hydrant:
Distance from the nearest fire hall:
Does the building owner live at this address?
Exterior cladding:
Building structure:
Year built:
Number of units in the building:
Roof shape:
Roof material:
What special features apply to your roof?
- Dormers
- Skylights
- Slopped roof gutters
Do you have a garage or a shelter of automobiles?
What is the type of your garage or shelter of automobiles?
How many cars can your garage or shelter of automobiles contain?
Do you have a thermal pump?
Are there any commercial or business activities in the building (operated or not by you)?
If so, provide details:
Are more than 50% of main rooms finished wood or ceramic flooring?
Electric panel type:
Primary heating source:
Auxiliary heating source:
Burglar alarm:
Fire alarm:
Water detection alarm?
Do you have a pool?
What type of your pool?
Year of installation:
Do you have a spa?
What type your spa?
Year of installation:
Does the residence is under construction?
Does the residence is currently under major renovation?
Do you rent this residence?
Term rental (if applicable):
Does the residence is vacant?
Number of Creditors:
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?
Foundation Type:
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?
If so, provide details:

Guarantees
Desired deductible:
Legal liability coverage:
Building insurance amount:
Do you currently have insurance coverage for water damage – Above ground water?
For what amount?
Do you currently have insurance coverage for water damage – Ground water and sewers?
For what amount?:
Do you currently protected from damage caused by water entry?
For what amount?
What other warranty you want?
Additional notes:

OWNER

Step 1 of 4

Owner # 1

Owner # 2

Informations

Residence:

If you have made renovations, please specify the year

Guarantees