Quotation Request for Home & Contents Insurance

General Information

Referred By

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Address

House/Apartment # Street Area/City Country

1. Who is your Current/Previous Insurer? (if you do not currently have insurance, put "n/a")(Required)

2. Are you seeking insurance for the Building, Contents or BOTH?(Required)

Building

Contents

Both

3. What type of structure is the building?(Required)

Please specify(Required)

4. Who Occupies the Building?(Required)

Please specify(Required)

5. What is the Current (recommended) Market Value of your Property? (if not applicable please put 0)(Required)

6. What is the Estimated Value of the General Contents of your home? (if not applicable please put 0)(Required)

i.e. Furniture, Appliances, Linens, Houshold Items, Tools, Clothes, Shoes etc./ EXCLUDING jewelry & electronics

7. What is the Estimated Value of the Electronic Equipment in your home? (if not applicable please put 0)(Required)

i.e. Television, Stereo, or any other related items

8. What is the Estimated Value of the Personal Electronic items in your home? (if not applicable please put 0)(Required)

i.e. Computers, Laptops, Cameras, Cell Phones

9. What is the Estimated Value of the Jewellery in your home? (if not applicable please put 0)(Required)

i.e. rings, earrings, bracelets, necklaces, luxury watches etc., containing precious metals or gemstones. NB: Valuation would be required

Total value to be insured:(Required)

10. Did you ever make a claim on your Home Insurance Policy before?(Required)

Yes

No

11. When was your most recent claim?(Required)

12. Can you give describe the details of what happened?(Required)

13. What was the claim amount?(Required)