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
Please choose... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Saskatchewan Yukon
Telephone	Fax
Current Employer (Optional)	Current Position (Optional)
Birth Date	Are you currently insured?
DD/MM/YY	Yes No If yes, how many years?
Are you retired?	Smoke Free?
Yes No	Yes No
Age of dwelling	Number of families in dwelling
Number of smoke detectors in dwelling	Fire extinguishers?
	Yes No
Fire Protection
Fire hydrants located within 300 metres of dwelling Dwelling located within 8 km of Fire Hall Located beyond 8 km but within 13 km of Fire Hall Located beyond 13 km of Fire Hall
Year updated (if over 20 years old)
Heat Electrical Plumbing Roof
Current Insured Value of dwelling
$ If no current insurance, the approximate value of dwelling. $
Claims history
Have you made any claims in the past 5 years? Yes No If yes, provide details.
External Construction material
Fire Resistive Masonry Brick Veneer Frame
Heating
Central Furnace Electric Hot Water/Steam Approved Combination Furnace Solid Fuel Space Heaters	Wood Burning Stove Fireplace Fireplace Insert Solar Other
Alarms
• Fire alarm Monitored Local • Intrusion Alarm Monitored Local