QUICK QUOTE REQUEST

Brokerage:	Policy Period: to (12:01 AM)
Applicant’s Name (Legal and Operating):
Applicant’s Address:
Location of Insured’s Property:
Mortgage Name and Address:
Single Family Vacant Rented Seasonal	Other Occupants: Yes, No
Construction Details:
Year Built:	Electrical: Fuses, Breakers
Roof:	Year Updated:	Hydrant Protected? Yes, No
Heating:	Year Updated:	Fire Hall? Yes, No
Plumbing:	Year Updated:	Distance from building(km):
Number of Units:	Square Footage:
Electrical:	Storeys (excluding basement):
Loss and Policy History
Any losses or claims by the applicant in the past 5 years? If yes, describe below: Yes, No
Previous Insurer:	Policy #:
Has any insurer cancelled, declined or refused to renew Insurance to the Applicant within the past 5 years? Yes, No
Supporting Business: Policy #:	Company:
Coverages Coverages NP BF Deductible ($) Coins % Amount of Insurance ($) Rate ($) Premium ($) Building Contents Outbuilding Rental Income Premises Liability $1000 BI&PD Ded. N/A M.R.P: $

Signature:	Date: