Home Insurance Quote – A M Luken Insurance & Financial Services Inc.

General Applicant(s) Information

Named Insureds are those listed/expected to be listed, on Title

Name of Insured 1*

First Last

Date of Birth*

Marital Status*

Occupation*

Name of Insured 2 (if applicable)

First Last

Date of Birth

Marital Status

Occupation

Home Address*

Address of the home being quoted

Street Address City Province Postal Code

Primary Phone Number*

Secondary Phone Number

Email*

Preferred way to contact you*

Phone

Best time to contact you*

Do you currently have a Home Insurance policy in force?*

Yes

When is the Renewal/Expiry Date

Years of continuous Property Insurance*

May include Renter's/Tenant's, Condo, Home Owners Insurance etc.

Please enter a number from 0 to 50.

Any Gaps/Lapses in Insurance History?

If Yes, please indicate the date and duration for any gaps in coverage

Have you been previously Cancelled by any Insurance Company for any reason?*

Insurance Companies can cancel for a number of reasons including Non-Payment, Misrepresentation, # of Claims, etc.

Yes

If you were cancelled for Non-Payment, is there any money owing for Time on Risk?*

Yes

Unsure

Cancelled for another reason

Claims History*

Have you had any Property Claims of any type in the past 5 years?

Yes

Please provide claim(s) details below*

Include the Date of Loss, Type of Loss (ex. Wind/Hail, Fire, Flood, etc.)

Future Claim Preventative Measures

If you've had prior claims, were any measures taken to help mitigate/prevent future claims?

Property Details

Please fill in as much information about your home below

Is there a Mortgage on the Property?*

Yes

Property Type*

Property Style*

Year Built*

Total Square Footage (not including basement)*

Is there a Bonus Room*

A Bonus Room would typically be above an Attached Garage

Yes

Total # Of Bathrooms*

Basement Type*

Basement Development*

Does the property have a Basement Suite?*

A Basement Suite would be described as a rentable unit complete with kitchen facilities with a separate entrance that may be rented to others.

Yes

If Yes, are the Tenants required to have their own Renters Insurance Policy?*

Yes

Does the Property have a Garage?*

Yes

What type of Garage?*

Any Decks/Porches?

If so, what is the size and building material used

Are there any Smokers in the Home?*

Yes

Structrual Component Details

Roof Type & Age*

What type of roof is on the home and when was it last updated?

Exterior Finish*

Material that the majority of the property is wrapped with, not including decorative trim

If Other, please provide details*

What type of Electrical Wiring does your property have?*

Copper Wiring

Aluminum Wiring

Mixed - Copper & Aluminum

Not Sure

What type of Electrical Panel does your property have?*

60 Amp Breaker

100 Amp Breaker

200 Amp Breaker

Fuses

Knob & Tube

Other/Not Sure

What type of Plumbing Lines does your property have?*

Copper

PEX

Poly-B

Mixed - Metal & Plastic

Other/Not Sure

Primary Heating Type & Age*

What is the primary Heating Type for the property and when was it last updated/replaced?

Water Heater Type & Age*

What type of Water Heater does your property have and when was it last updated/replaced?

Does the property have a Backwater Valve installed?*

A backwater valve would be installed on your sewer line and is designed to prevent water or sewage from backing up into the property

Yes

Unsure

Does the property have a Sump Pump installed?*

A Sump Pump would be installed in a pit in the basement of the property and designed to move water away from the property

Yes

Unsure

Does the Home have an Alarm System installed?*

Check all applicable boxes

Local System (Not Monitored)

Monitored - Fire/Smoke

Monitored - Burglar

Monitored - Water Sensors

None

Is there a Sprinkler System in the property?*

Yes

Property Coverage Information

Please select the preferred coverage's and deductibles you'd like quoted below

Preferred Deductible Amount*

$1,000

$1,500

$2,000

$2,500

Other

Liability Limit*

Additional Coverages*

Please select all of the additional coverages you would like included in your quote

Sewer Backup

Overland Water

Ground Water

Service Line Coverage

Bylaws Coverage

Identity Theft

Disappearing Deductible

Any Scheduled Articles?

Scheduled Articles may include Jewelry, Hearing Aides, etc. Please list items and replacement value required

Additional Information/Comments

Any additional information or details you would like to provide can be entered below.

Consent & Disclosure

As your broker, I am gathering this consent on behalf of the insurer who advises me that: in respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may collect, use and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law and in accordance with our privacy policies.

Authorization*

I authorize you, and on behalf of others listed, to collect, use and disclose to appropriate third parties, this information solely relating to your personal insurance policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settle claims, analyze business results and detect and prevent fraud?*

I Agree

Acknowledgement*

I have reviewed, and confirm that the answers provided in this questionnaire are correct and true to the best of my knowledge and I have not suppressed or misstated any facts. Submitting this form in no way binds any coverage for the Applicant or Company however it is agreed that this form shall become part of the contract should a policy be issued though our agency.

I Agree