Cottage Quote Form

BrokerForce Insurance Inc.
200 Consumers Rd. Suite 608
Toronto, Ontario M2J 4R4

Toll free:
800.263.9870
GTA:
416.494.2696
Fax:
416.494.7130

Name:
 Last: First:
Primary
Address:
City:
Province: Postal Code:

Phone 1:
Phone 2:
Fax:
Email:

Desired effective date:
(Month ##, ####)
Cottage
Cottage
Address:
City:
Province: Postal Code:

Cottage
Phone:
  Date of Birth:
(insured)
Month ##,####		 Date of Birth:
(co-insured)
Month ##,####
Year Built: Number of Stories:
Ground floor Area (Foundation size): x = sq. ft.
Construction Type:
Brick
Brick Veneer
Frame
Siding
Stucco
Stone
Log
Detached
Semi-Detached
ORRow House #of Units Attached:
Basement: Yes No    

Protection:
 Protected (fire hydrant within 300m)
  Semi-protected (Firehall within 8km) Name:
Unprotectetd

Heating
  
Last Updated: Full: Partial:
Type:
Fuel:
Wood Heat: Cords/Yr: Bush: Face:
Wiring
  
Last Updated: Full: Partial:
Amps: 60 100 200 Breakers: or Fuses:
Type: Copper: Aluminum: Knob & Tube:
Roof
  
Last Updated: Full: Partial:
Material: Shingles: Tar & Gravel: Metal: Clay Tile: WoodShake:
  Other:
Plumbing
  
Last Updated: Full: Partial:
Pipes: Copper: Plastic: Galvanized:
Source: Municipal: Cistern: Well:
Waste: Sewer: Septic:

Bathrooms and Basement
No. of Bathrooms: 2 piece 3 piece 4 piece Rough-in
Foundation type: concrete block: concrete: pier:
(wood or concrete)		 slab/pad:
Basement finished as: Apartment: Rec. Room: Unfinished:
  Other: describe
Percent of basement finished: Walkout basement:

Heating and Air Conditioning
Central A/C: orHeat Pump: --using--> Heating ducts: or Separate ducts:
No. of
fireplaces :		 different chimney: same chimney:
Wood:
Gas:
inside wall: outside wall:
If Gas, is chimney 'direct vent'? Yes No
Oil tank on premises? Yes: No: If Yes, Outside: Inside: Year of Tank?

Other
Garage: orCarport: # of vehicles: Attached: or Detached:
Material: Year Built:
Boathouse: With living space above
Sq.footage: Material: Approx. value

Porches: Wood: Masonry: Fiberglass: Other:
  size: x = sq. ft. Covered:
Decks: Wood: Masonry: Fiberglass: Other:
  size: x = sq. ft. Covered:
Swimming
Pool:
In-ground: Above ground:
Concrete: Vinyl:
  Size: x = sq. ft.
Hot Tub:
In-ground: Above ground:
Concrete: Fibreglass:
  Size: x = sq. ft.

Extra Kitchen
Skylights
Wet Bar
Interior Sprinkler System
Central Vaccuum
Jacuzzi/Sauna
Intercom System
Carbon Monoxide Detectors

Central Burglar Alarm Central Fire Alarm
Monitoring Company Local Alarm only

Mortgage and Insurance
Mortgagee:
Name
and
Address
Mortgage free:
Current Insurance
Company:

Policy #: Expiry Date:

Cancellation of any kind in the past 5 years? If so, please provide dates and reasons:


Claims History for Past Five Years:

Non Smokers

Remarks: