Need Home Insurance.ca | Your Home and Renters On Line Quote Form


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Welcome

On Line Home and Renters Quote Form

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General Information

Your Name:
Street Address:
City:
Province:
Postal Code:
Email (REQUIRED):
Email Again for Accuracy:
Phone:
Fax (optional):
Marital Status: Single Married	Homeowner or Renter? Home Renter
Currently Insured?	Yes No
Current Insurance Company?
Current Real Estate Value

Dwelling Information

Year Home Built:
Home Square footage:

Is there a woodstove?	NO YES

Do you rent this house to other families or renters?	NO YES

# of Families Residing in Home:

Does Your Home Have a Basement?

Prominent Exterior WallConstruction:

Type Roof:

Number of stories:

Do you have an in-home business or daycare?	Yes No
If yes, list type of business / # of children:
Do you have a monitored burglar alarm system?	Yes No
Are You a Smoker?	Yes No

Do You Drink Alcohol?	Yes No

# of meters to fire hydrant:	# of kms to fire hall:


Any Claims in last 3 years?	Yes No
Describe claims in detail:

Has any insurer cancelled or refused you insurance in the last 3 years?	Yes No

Primary Policyholder's Birthdate: (discount may be available)

Plumbing type:


Heating Type:

Circuit Breakers or fuses?	Breakers Fuses

# Bedrooms:		# Bathrooms:

# Fireplaces:		# Chimneys:

Special features (i.e., deck, air conditioning, alarm systems, pool, hot tub, wet bar etc.)

Coverages

Dwelling Amount Home Only $		Contents $
Liability Cov. $

Comments or Remarks:

Send My Quote Via

E-Mail	Fax
Call me by Phone!	Regular Mail

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You are applying for automobile insurance based on the information provided above as well as any information that may be available from reports ordered on your drivers license and auto insurance. This information may include a history of tickets, license suspensions, insurance claims, non-payments and cancellations. You authorize needcarinsurance.ca to collect and disclose information as permitted by law and required by insurance companies for the purposes necessary to assess your application for new or renewal automobile insurance, investigate and settle claims and detect and prevent fraud. You also agree that needcarinsurance.ca may collect and use this personal information to consider your on-going needs for insurance products and information. You understand that your personal information may be disclosed pursuant to any relevant privacy laws or other laws.

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Absolute Insurance Brokers

12 Second Street

Orangeville, Ontario L9W 2B5

toll free 877-941-2266 / local tel. 519-941-2266

fax. 519-941-2267

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