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| Have you ever had insurance cancelled or refused*: |
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| Do you currently insure your property: |
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| Expiry date with present Insurer: |
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| What is your date of birth: |
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| If property over 20 years old, which of the following have been replaced: |
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| Are you within 300 m of a hydrant: |
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| Are you within 13 km of a firehall: |
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| Discount Information |
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| Amount of coverage Required |
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| Recent Claims |
| Type | Date | Location Involved |
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| #1: |
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| #2 |
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| #3 |
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