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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 *

Last Name *

Street *

City *

Province *

ZIP / Postal Code *

Primary Phone Number *

Alternate Phone Number

E-Mail Address *

Policy Information

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

If yes, please provide details

Please advise the age of the following

Roof *

Hot Water Tank *

Furnace *

Please advise the approximate date your furnace was last serviced *

Have you started a business out of your home? *

If yes, please provide details

Have you installed a woodstove in your home? *

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

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

Are you a non-smoking household? *

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. *

How many families are living in your home? *

Do you rent out rooms to boarders? *

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

***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

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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