Home Insurance

 

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Note: Only available to residents of New Brunswick

 

Name:
Address:  
City:     
Province:  
Postal Code:
Phone Number:  
Have you ever had insurance coverage cancelled or refused? Yes No
Do you currently insure your property? Yes No
Number of years prior insurance:
Expiry date with present insurer (dd/mm/yyyy):  
What is your date of birth (dd/mm/yyyy)?  

 

Property Information         Property #1        Property #2
Property type:  
Use:  
Do you:   
Year built    
      
If property is over 20 years old,                       
which of the following have                              
been replaced








Alarm system: 
If yes, is alarm   
Are you within 300m of a hydrant?   Yes No Yes No
Are you within 13 km of a firehall? Yes No Yes No
Principal heating type:
If oil heat, age of tank (in years):
Location of tank:




Indicate any auxiliary heat options:



Other (specify)



Other (specify)

Discount information:  I am a non-smoker
I am mortgage-free		 I am a non-smoker
I am mortgage-free

 

Amount of coverage required   or presently insured for Property #1    Property #2
Building:  
Contents:  
Liability:   
Deductible  
Recent claims:    Type        Date(mm/yyyy) Location
#1
#2 
#3    

 

 

I give my consent for Kent and White Insurance to use this information for the purpose of obtaining an accurate insurance quote. This information will not be used, or shared with any other parties, for any reason other than obtaining an accurate insurance quote.
I accept
I do not accept

 

 





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