Homeowners Insurance Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What's your home address? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you rent or own this property? *

Rent

Own

Are you closing on a new home or just thinking of switching insurers? *

I'm closing on a new home

I'm thinking about switching

Other

Building Type *

Single Family

Duplex

Triplex/Fourplex

Who lives in your home?

It's just myself

We're a couple

Couple with children

My children and I

Other

Which best describes the condition of the home?

Needs work

Standard

High

Superb

How do you heat your home? *

Gas

Oil

Other

Have you had any substantial renovations on the home?

Yes

No