Please fill out the details in full below and submit. Once reviewed, our team will contact you with a quote, or we may require more information. Home Insurance Questionnaire Residential Insurance Questionnaire 2026Δ Name on TitleD.O.BSmoker Yes NoCell PhoneE-Mail AddressAddress of Dwelling Requiring CoverageMailing Address (if different than above)What Date is Coverage Required?Previous Insurance InformationInsurance CompanyEffective DatePolicy #Expiry DateNumber of consecutive years you have had home/condo/tenant insuranceHave you had to make any property insurance claims in the past 5 years? Yes NoIf yes, please describe when claim occurred, the cause of the claim, and approximate payoutDateCause of claim$ AmountHas any insurer cancelled, declined or refused to renew your insurance? Yes NoDwelling InformationYear Built# of Full BathroomsSquare Feet# of Half Bathrooms# of Families in Home# of KitchensIs there a mortgage on the home? Yes NoIf yes, please list lender and addressCan we have someone from Remple & Dusyk Financial contact you for quotes on Term or Permanent Life insurance? Yes NoDo you consent to a Soft Credit check for discount purposes? Yes NoOccupancy Owner Rented Family Occupied Vacant Other (please specify)OtherArchitectural Style Bungalow (1 storey) 1 ½ Storey 2 Storey 2 ½ Storey Bi-Level Tri-Level Other (please specify)OtherFoundation Concrete Concrete Block Wood Other (please specify)OtherFoundation Type Basement Walkout Crawlspace Slab Other (please specify)% FinishedOtherRoofingYear Last UpdatedRoofing Asphalt Shingle Wood Shingle/Shake Metal Clay Other (please specify)OtherExterior Siding (% of each) Vinyl Wood Stucco Brick Other (please specify)% (Vinyl)% (Wood)% (Stucco)% (Brick)OtherOtherElectricalYear Last UpdatedElectrical Copper Aluminum Knob & Tube% (Copper)% (Aluminum)% (Knob & Tube)Amperage of Breaker Box: (listed in box) 75A 100A 200A Other (please specify)OtherHeatingYear Last UpdatedHeating Central Gas Furnace Electric Boiler Other (please specify)OtherAux. Heating# of FireplacesType Wood-Burning Gas Insert Direct Vent (Gas)Water HeaterYear Last UpdatedType: Tank TanklessFuel Natural Gas ElectricPlumbingYear Last UpdatedPlumbing PEX Plastic (PVC/ABS) Poly B Copper Other (please specify)OtherGarage/Outbuildings Yes No# of CarsType Attached Detached Other (please specify)OtherSewer/SepticType Municipal Sewer Private SepticBackwater Valve Yes NoYear InstalledSump Pump / Sump Pit Yes NoYear installedMiscellaneousIs the home on a farm/acreage? Yes NoIs home used for business at all? Yes NoIs any part of the home rented out? Yes NoIs there a centrally monitored alarm? Yes NoExtra Coverage (needed for the following) Artwork / Collectors’ Items Business Contents Jewelry Solar Panels Swimming Pool / Hot Tub Watercraft / ATV / Side x Side Other (please specify)OtherSubmit
