Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Do you have a fireplace? *

yes

no

Do you have a woodstove? *

yes

no

Do you have a pool? *

yes

no

Do you have a garage? *

yes

no

Do you have a trampoline?

yes

no

Do you have a basement?

yes

no

Do you have pets or dogs?

yes

no

Have there been any claims or non-renewed?

yes

no

Do you own any other properties?

yes

no

Is the home rented out?

yes

no