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
DD/MM/YY
Are you currently insured?
Yes No If yes, how many years? Name of Insurance Company Expiration Date DD/MM/YY
Have you had previous property insurance?
Yes No
Claims history
Have you made any claims in the past 5 years? Yes No If yes, provide details.
Other Considerations
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.
Located in
House Apartment Building Number of units
Located in Commercial Building?	Contents' Value
Yes No	$
Location Address