Home Insurance

Please complete the form below as accurately as possible in order to ensure the best possible estimate for your homeowners insurance.
The home insurance program is available to residents of Ontario only.


Fields marked by an asterisk (*) are required fields.
Contact Information
Privacy Consent: By completing this form, you are giving us permission to use your information for the purpose of providing an insurance quote,
council or risk management service. Please read our Privacy Statement for more information.

Your Name  *
Home Number
Business Number
Cell Number
Fax Number
Email Address  *
APPLICANT INFORMATION
Registered Owners  *
Applicant 1 Date of Birth: (mm/dd/yyyy)  *
Applicant 2 Date of Birth: (mm/dd/yyyy)  *
Number of claims in the last 5 years  *
If you had claims, details of claims (loss date, description, amount paid out)
How many mortgages are on the house?  *
Are all members of the household non-smokers?
Consecutive years you have had insurance  *
Current Insurer
enter 'None' if no current insurance
 *
Expiry Date/Date Insurance Required: (mm/dd/yyyy)  *
Amount of insurance required for your home
What is your current annual premium?
Do you presently have auto insurance?
Reason for a new insurer or broker
How did you hear about us?
LOCATION & DWELLING INFORMATION
Address  *
City (Ontario Residents Only)  *
Postal Code  *
What is the square footage of your home?  *
What year was your home built?  *
If the home is over 25 years of age, what year were the following updated?  Roofing
 Heating
 Electrical
 Plumbing
Number of Stories  *
What is the structure of your dwelling?
What is the exterior of your dwelling?
How far is fire hydrant from your residence?
How far is your residence from a fire hall?
Do you, as owner, occupy the dwelling?
Number of families occupying the dwelling.
Construction of Basement Foundation (the totals should equal 100%)
Block Foundation %
Cast Concrete Foundation %
Concrete Slab %
Percentage of basement that is crawlspace % Enter percentage that is crawlspace
Is your basement finished? % Enter percentage completed
Primary heating and/or cooling source
Auxiliary heating source if any
Electrical
Electrical - Amps
Plumbing
Roofing
Garage
If garage is detached, what is the exterior?
Number of cars in the garage
Number of kitchens in the home
Type of Ceiling
What is the height of your ceiling?
Number of Bathrooms Full     Half   
Wall Partitions Drywall % Plaster %

Flooring
 
Hardwood  % Carpet Over Hardwood  % Wall to Wall Carpet  %
Vinyl % Ceramic Tile % Imported Ceramic Tile %
Parquet % Plank % Marble Tile %
Slate % Laminate % Plywood Only %

Wall Covering
Paint % Vinyl Wallpaper % Tongue & Groove %
Sheet Panelling % Solid Wood Panelling % Other %
 
Deck Square Footage 
Porch Square Footage 
Breezeway Square Footage 

Additional Features or Special Items (check all that apply)
Central Fire Alarm  Central Burglar Alarm  Sprinkler System 
Central Vacuum  Skylights  Swimming Pool 
Jacuzzi  Hot Tub  Sauna 
Kitchen Upgrades  Bathroom Upgrades  Gazebo 
Cabana  Sun Room  Solarium 
Window Upgrades  Door Upgrades  Air/Heat Exchanger 
ADDITIONAL COVERAGE
Enter the values of additional items that require protection below.
Jewellery
Fine Arts
Furs
Bicycles
Musical Instruments
Golf Clubs

ADDITIONAL COMMENTS

Address: 501-1500 Don Mills Rd., Toronto, ON, M3B 3K4    Email: info@aibrokers.ca   
Phone: 1-877-213-4545 or 416-484-4545   Fax: 416-900-0322   24-Hour Claims Service: 1-888-235-2447

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