Homeowners, Seasonal & Rental Property Online Quote CONTACT INFORMATION Surname: * First Name: Address: Age of oldest insured: Telephone: E-mail: * City: Province: * Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code: Employer/Association: RATING INFORMATION Occupancy: Principal Residence Secondary Residence Seasonal Residence Owner Occupied Tenant Occupied Other Structure Type: Detached Semi-Detached Townhouse Apartment Construction: Masonry Brick Veneer Frame Other Primary Heat: Electric Gas Oil Woodstove Auxilary Heat: Fire Protection Fire Hydrant Firehall Unprotected Square footage, ground floor: Number of Floors: Bungalow 2 Storey 3 Storey Split Level Other Finished Basement? Yes  No If yes, square footage: Deck? Yes  No If yes, square footage: Porch/Veranda? Yes  No If yes, square footage: Garage? Yes  No If yes, then: Attached Detached     One Car Two Car Central Air? Yes  No Central Vac? Yes  No Fireplace? Yes  No Is there a Mortgage? Yes  No Are you Smokers? Yes  No Alarm System? Yes  No    If yes, is it monitored for burglary? Yes  No      If yes, is it monitored for fire? Yes  No      If yes, is it local? Yes  No Pool? In Ground  Above Ground  No Number of bathrooms? Year Built: If older than 20 years, indicate last updates for: Heating   Electricity   Roof   Plumbing INSURANCE INFORMATION Any prior insurance coverage? Yes  No Any claims in the past 5 years? Yes  No             If yes, explain: Do you require additional coverage i.e. valuables/watercraft? Yes  No             If yes, explain: Renewal Date: (mm-dd-yyyy) Please tell us how you found our site: Fairlie Insurance Agency CAUT A search engine Referred by a friend Other

INSTAR Insurance Brokers Inc.
2435 Holly Lane, Suite 200
Ottawa, Ontario K1V 7P2

Toll Free: 1-888-769-9299
Local: (613) 228-1600
Fax: (613) 232-6486
info@instar.on.ca