Buckler Insurance Service Ltd. - Home/Condo/Tenants Insurance

Name*:

Address*:

City:

Province:

Postal Code (X1Y 2Z3):

Phone Number (123-456-7890)*:

Email:

Have you ever had insurance cancelled or refused*:

YesNo

Do you currently insure your property:

YesNo

Number of years prior insurance:

Expiry date with present Insurer:

What is your date of birth:

Property #1

Property #2

Property Type:

Use:

Do you:

Year Build:

If property over 20 years old, which of the following have been replaced:

Furnace
Roof
Wiring
Plumbing

Is property equipped with an alarm:

If yes, is alarm:

Are you within 300 m of a hydrant:

YesNo

Are you within 13 km of a firehall:

YesNo

Discount Information

I am mortgage-free:

I am a non-smoker:

Amount of coverage Required

Building:

Contents:

Liability:

Deductible:

Recent Claims

Type

Date

Location Involved

#1:

#2

#3

Comments:

Quotes