Home Insurance | Condominium | The Insurance Centre

Fill out the form below, and click "Go" and someone from The Insurance Centre will get in touch with you. You can also print this form, fill it out and fax it to 613.542.6249 ... whichever is more convenient for you.

If you don't feel comfortable filling out the online application, please email your name and phone number and a representative will get in contact with you to discuss your needs.


Name (First, Last)	Email

Address	City

Province	Postal Code

Telephone	Fax

Current Employer (Optional)	Current Position (Optional)

Birth Date
DD/MM/YY
Are you currently insured?
Yes No If yes, how many years? Name of Insurance Company Expiration Date DD/MM/YY
Claims history
Have you made any claims in the past 5 years? Yes No If yes, provide details.
Other Considerations
Do you have a mortgage? Yes No Has any insurance company cancelled, declined or refused to renew or issue property insuarance in the last 5 years? Yes No If yes, provide details. Please describe any watercraft or valuable items that need to be added to your policy.

Number of units in building

Building Address

Current Insured Value
$ If no current insurance, the approximate value of the unit $

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