Personal Information

First Name:

Last Name:

Address:

City:

Province: *Ontario Residents Only

Postal Code:

Home Phone:

Work Phone:

Ext.:

E-mail:

Do you currently have a policy with Meadowvale Insurance Brokers? Yes 
No

Date of Birth of Homeowner:

Have you ever been refused for property insurance? Yes No

Do you currently have automobile insurance? Yes No

Property Information

Type of home:  Detached Semi-Detached Inside Row House Outside Row House

Year of Last Update: (Applicable only if home is older than 25 years)

• Heat:
• Electricity:
• Plumbing:
• Roof:

Year Home Built:

Alarm System:  None Fire Burglar Burglar & Fire

If you have an alarm is it:  Local Monitored

Is your property located:  300m of a Fire Hydrant 8km of a Fire Hall Neither

Coverages

Building Amount:

Liability Amount:  $1,000,000 $2,000,000

Deductible Amount:  $300 $500 $1,000

Comments

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