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Home Evaluator Form (EZITV)

Applicant Information

First & Last Name:
Date of Birth:
Name on Title:
Additional named insured:
Date of Birth:
Dwelling Address:
Phone Number:
Mortgage Address:

Dwelling Details

What is the square footage of the home not including the basement?:
What year was the home built?:
What is the architecture style of the home?:
Construction Type:
Construction Quality:
Physical Shape (from overhead view of home):
What is the primary siding?:
Type of roofing material:
Bathrooms? (Not including those in basement):
Description of Location (check all that apply)
City, Large:
City, Medium:
City, Small:
Exclusive Pocket:
Gated Community:
Island, Accessible by boat:
Island, Accessible by bridge:
Remote, Moderate:
Remote, Slight:
Remote, Very:
Has the home been completely gutted in the last 40 years?:
Is the home listed on the Historic Registry?:
Is there a garage?:
If so, how big is the garage (how many cars)?:
What type of garage?:
Garage Year Built:
Do you have a carport?:
If yes, how many cars?:
Carport Year Built:
Is there a deck?:
If so, what size is the deck (sq. ft.)?:
What type of deck is it?:
Deck's year built:
Deck Material:
Is there a porch?:
If so, what size is the porch (sq. ft.)?:
What type of porch is it?:

Additional Areas
For each additional area below that applies to the home please include the Sq. Ft. and the year built:
1/2 Storey:
3/4 Storey:
Attic (Finished):
Attic (Unfinished):
Basement (Finished below grade):
Percentage of basement finished:
Basement (Finished walk out):
Basement (Garden level):
Basement (Partially Finished):
Basement (Partially finished walk out):
Basement (Unfinished):
Basement (Unfinished walk out):
Basement (Unfinished with breakaway walls):
Bonus Room:
Breeze Way:
Crawl Space:
Crawl Space with breakaway walls:
Finished room over garage:
Indoor swimming pool:

Scheduled Items (Contents requiring additional coverage due to special limits)
Travel Trailer:
Hydrant Protected:
Hydrant Meters:
KM to Firehall:

Furnace (Type and Year Updated):
Furnace Last Serviced:
Plumbing (Type and Year Updated):
Hotwater Tank (Type and Year Updated):
Electrical (Type, Amps, and Year Updated):
Wood Heat:
Wood Heat Type:
Wett Inspected, Professionally Installed:
Back water valve:
Sump Pump:
Alarm System:
Alarm System Certificate:
Business use:
Business use type:
Additional location:
Additional location type:
Years at current location:

Sewer Backup:
Sewer Backup Limit:
Service Line:
Previous Insurance:
Claims (5 Years):
Auto Insurance:
Auto Insurance Year:


Please indicate which Western Financial Group branch you prefer to work with:


If you bundle car and home insurance, you can earn additional discounts and savings. Would you like a quote on car insurance to maximize your discounts?:

Privacy Consent

Your privacy is important to us. In order to offer you products and services from our insurance partners, as well as submit claims and manage related inquiries, we will be collecting personal information from you. This information may be used by our insurance partners to collect data from other external sources, including other property and casualty insurers, or claims information databases. This may also be used in the prevention, detection and prosecution of fraud. In order to continue with this application, we require your consent to collect, use, and disclosethis information as reasonably required for the purposes I have described. You can review our privacy policy on the internet by going to www.westernfinancialgroup.ca
Do we have your consent to use and share the personal information you will provide to us as described?:

Credit Consent

In order to provide the most accurate quote, the insurance markets may need to access your credit history information. Doing so may allow you to obtain a lower quote for your insurance, however, not providing consent will not prevent you from receiving a quote.
Do we have your consent to access and use your credit history information as described?:
I look forward to hearing from you and delivering you the Western insurance advantage!