Request for Quotation
 
 

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The Mural

 

In order for us to provide you with an insurance quote, we need to know some information.  Please fill out this questionnaire to the best of your knowledge. We will get back to you with a quote as soon as possible.

Full name:

Address:

City/Town:

Postal Code:

Date of Birth:
  (enter as mm/dd/yyyy)

Telephone - Home:

Telephone - Cell:

Email:

Are you a member of Assiniboine Credit Union?
Yes    No

Are you an employee of Assiniboine Credit Union?
Yes    No

 

Policy Renewal Date:

Date first moved into home:

Current insurance company?

If less than 5 years, please provide previous address:

 

# years of consistent insurance? 

# years with current broker? 

Is there a mortgage on the house?YesNo

  

Any claims in the past 5 years?YesNo

If yes, please describe: (date, type of loss, amount paid)

What type of flooring do you have?

ceramic tile %

hardwood %

vinyl %

carpet %

Are there smoke detectors in the house?YesNo

Any smokers live in the home?YesNo

Do you have an alarm?YesNo

Burglar alarm:  Local Central Station Monitored

Is there a sump pump? YesNo

Is there a backwater valve?: YesNo

Business or farming on the premises? YesNo

Year house was built? 

Any outbuildings? YesNo

How many: 

Heating in outbuilding? YesNo

Heating:
Year furnace was last updated? 

Heating:
Fireplace? YesNo

Woodstove? YesNo  

Electrical:
60, 100, 200 amp? 

Electrical:
Circuit breakers or fuses? 

Wiring:
Copper, aluminum, knob or tube? 

Plumbing:
Copper, plastic, galvanized, mix?   

Roof:
Year updated? 

Roof:
Type of shingles? 

 

# stories? 

Ground floor square footage: 

Is there a basement? YesNo

If yes, is it finished? YesNo

What type of siding do you have?

wood %

stucco %

vinyl %

brick %

stone %

Is there a sunroom? YesNo
If yes, how many sq. ft.? 

Is there a porch? YesNo
If yes, how many sq. ft.? 

Is there a deck? YesNo
If yes, how many sq. ft.? 

How many full baths? 

How many 1/2 baths? 

Central Air Conditioning? YesNo

Is there a hot tub? YesNo

If yes, how many persons? 

 

Is there a pool?  YesNo

If yes, is it above ground? YesNo

Surface area of pool? 

Attached garage?  YesNo

If yes, how many cars? 

 

 

Coverages:

Comprehensive or standard:  comprehensive standard
(note, 1st time insurers qualify for standard only)

$500 or $1,000 deductible:  $500 $1,000
(note, 1st time insurers qualify for $1,000 deductible only)

$50 lower glass deductible: YesNo

Sewer backup coverage:  $5,000 $15,000 $25,000
(note, if dwelling does not have sump pump or backwater valve, then only qualify for $5,000 with $1,000 deductible)

Do you have any scheduled articles (i.e.  jewellery, furs, arts, etc.) currently listed on your policy or that you would like added to this quotation?  YesNo

If yes, please describe: 

 
 

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