Your Full Name
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Personal Email Address
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Contact Number
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Broker Person Referral Name
Best time to call for 10-15 Min's to discuss quote?
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Information about the property owner, their name, date of birth, email address, and the name, date of birth, and email address of their spouse. If there are other owners on the property
What is the address of the home you would like to obtain insurance for?
Can you tell me the exact date, month, and year that you purchased your house?
What is square foot of house? 1000 or 1400 or 2000
What is the construction year of the house? Example 2000 Year
Is your house detached or Bungalow, semi detached or town house or condo town house or free hold town house ?
If you live in condo town house do you pay monthly fees? if yes does it cover your building insurance?
How many total washrooms in home?
Is basement finished ? Is it walk out with separate entrance ?If yes are you renting it to student or family?
Do you have garage in house with 1 parking or 2 parking? Is it attached or built in
How many bedrooms you have in whole house including basement?
How many levels does the building have if you reside in a condominium?
When was last Electrical update done in your home?
When was last Plumbing update done in your home?
When was last roofing update done in your home?
When was last heating update done in your home?
When was last water heating update done in your home?
How many smoke detector in home?
Are you in high risk water territory ? Do you have sump pump? If yes provide details of it pleas
If you are home owner & renting your home than fill the info below
Yes
No
What is your annual rental income per year?
Are you renting your home to working professionals or family or students?
Who is responsible for house maintenance, Are you checking monthly?
Do you need sewer back up coverage in your house?
I agree to the
Chase Insurance Brokers to perform a soft credit check for home/tenant insurance quotes. This will not affect my credit score.
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