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Homeowners Renewal Questionnaire

By taking a few minutes to fill out and return this brief checklist, your nation West agent can help make sure that your insurance coverage is up-to-date and complete. Information submitted will be help confidential and will be used for renewal purposes only. Submission of information does not obligate you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information

First Name

Required

Last Name

Required

Street

Required

City

Required

Province

Required

ZIP / Postal Code

Required

Primary Phone Number

Required

Alternate Phone Number

Optional

E-Mail Address

Required

Policy Information

Have you made any upgrades or additions to your home in the last year?

Required

If yes, please provide details

Optional

Please advise the age of the following

Roof

Required

Hot Water Tank

Required

Furnace

Required

Please advise the approximate date your furnace was last serviced

Required

Have you started a business out of your home?

Required

If yes, please provide details

Optional

Have you installed a woodstove in your home?

Required

Have you added, changed or paid off a mortgage holder in the last year?

Required

Has an alarm system (local or monitored) been installed in the last year?

Required

Are you a non-smoking household?

Required

If you have lived at your current address for more than 5 years, you may qualify for a stability discount. Please confirm your move-in year.

Required

How many families are living in your home?

Required

Do you rent out rooms to boarders?

Required

Would you like a quote on higher limits or liability? Limits up to $5Million are available.

Required

***Did you know that Sewer Back-up Coverage is only available to add or increase when your policy is new or renewing? Please contact our office if you would like to discuss adding or increasing Sewer Back-up Coverage.

**Did you know that most insurance companies insure your jewelry up to $6,000.00 (subject to your deductible)? If your jewelry exceeds this amount, you may want to call us to discuss your options.

Submission Validation

Required

Enter the Validation Code from above.

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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