Home Insurance Quote Form

Thank you for choosing our Western Financial Group licensed experts for your home insurance quote. At Western, we have access to a large number of partners and can ensure you will receive value and the right security for your insurance needs.

I wanted to follow up with you and get some information. We’ve tried to connect with you by phone and want to service your insurance request. Please either call us back or answer the following questions.

Tell us about yourself to ensure you qualify for appropriate discounts and an accurate price:

Applicant Information
Are you an existing Western Financial Group Customer?:
First & Last Name:
Date of Birth:
Phone Number:
Email Address:
Gender:
Effective Date of Policy:
Are you a student?:
Occupation:
Home Occupancy Date:
Number of Families:
Number of Units:

Co-Applicant Information
First & Last Name:
Date of Birth:
Gender:
Relation to Applicant:
Are you a student?:
Occupation:

Dwelling Details
Street Address:
City:
Postal code:
Mailing Street Address (If different than dwelling) :
Mailing Address' City (If different than dwelling):
Mailing Address' Postal Code (If different than dwelling) :
Possession date:
Dwelling within 300 m (1000 ft) of a Fire Hydrant?:
Are you more than 8 kilometres away from a firehall?:
Are there any smokers in the home?:
Number of Mortgages:
Mortgagee Name:
Mortgagee Address:

Security System
Alarm System:
Burglar Alarm:

Building
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:
How many bathrooms are there?:
Description of Location (check all that apply)
Beachfront:
City, Large:
City, Medium:
City, Small:
Coastal:
Exclusive Pocket:
Gated Community:
Island, Accessible by boat:
Island, Accessible by bridge:
Remote, Moderate:
Remote, Slight:
Remote, Very:
Resort:
Rural:
Suburban:
Town:
Urban:
Waterfront:
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:
Is there a porch?:
If so, what size is the porch (sq. ft.)?:
What type of porch is it?:
Is there a basement?:
If so, what is the square footage?:
Is the basement finished?:
Is it a walkout?:
Do you have a hot tub or a pool?:
Is there a home-based business operating from the home?:
Is there a fireplace or a wood stove?:
If yes, has there been WETT inspection?:

Please comment if any of the following have been updated and what year it was done.
Electrical
What type of electrical wiring is it?:
Panel Type:
What type of amp is the electrical?:
Has the electrical source been updated and what year was it done?:

Heating Source
What type of heat is it?:
Furnace Last Serviced:
Has the heating source been updated and what year was it done?:
Chimney Type:
Secondary Heating?:
If Yes, Heating Type:
Wett Inspected, Professionally Installed:

Roof
Roof Material:
Year Updated?:

Plumbing
What type of plumbing material was used?:
Year Updated?:
How old is your hot water tank?:
Has the plumbing been updated and what year was it done?:
Hot Water Tank:
Hot water tank year installed:
Hot water tank - is it a storage tank or tankless?:
Do you have a sump pump?:
Do you have a back water valve?:
Water/Leak Detection:
Number of sensors:

Risk
Are there any roomers or boarders?:
Is there any commercial use of this dwelling besides self-employment?:
Is the dwelling under construction?:
Is the dwelling considered a heritage home?:
Is the main heating source electric, and the electrical panel less than 200 amps?:
Is there a home based business?:
Is there property in storage?:
Do you require additional coverage on items with special limits or items that need to be scheduled?:
If yes, please list the scheduled items:

Insurance History
Current Insurer:
Have there been any gaps in Insurance History?:
If yes, what length in gap?:
Reason for gap:
Has your insurance ever been cancelled, refused or lapsed?:
If yes, explain:
Since when have you have you had a continuous insurance policy?:

Claims History
Have you had any claims in the last 7 years?:
1 - Claim Date, Type & Amount Paid:
2 - Claim Date, Type & Amount Paid:
3 - Claim Date, Type & Amount Paid:
If claims resulted from water damage, select what type:
Sewer Backup:
Pipe Break:
Roof Leak:

What date would you like your policy to start?:
Please indicate which Western Financial Group branch you prefer to work with:

DID YOU KNOW?
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!