Insurance for Homeowners


Your Name:

E-Mail Address:

Telephone Number (between 9am-5pm): ( )


Postal Code :

When do you want coverage to begin? (DD/MM/YYYY):


Does your home have smoke detectors?  

Is your home within 300m (1000 ft) of a fire hydrant?  

Is your home within 13kms (8 miles) of a fire hall?  


Size of your home: 

Prominent Exterior Wall Material

If other, please describe:

Does your home have a basement?

% basement % Crawlspace
% finished % Slab (No basement or crawlspace)

Will your home have a mortgage? Yes No


Does your home have a monitored burglar alarm system?   

What year was your home built?

Do you currently have home, condominium or tennants insurance?

If yes, for how long have you been a policyholder? 

Have you had any home insurance related claims within the past
three years?   

What is your birth date? (DD/MM/YYYY):

You are applying for habitational insurance based on the information provided above as well as any information that may be available from reports ordered on your property. This information may include a history of insurance claims. You authorize Easyway Insurance Brokers Inc. to collect and disclose information as permitted by law and required by insurance companies for the purposes necessary to assess your application for new or renewal habitational insurance, investigate and settle claims and detect and prevent fraud. You also agree that Easyway Insurance Brokers Inc. may collect and use this personal information to consider your on-going needs for insurance products. You understand that your personal information may be disclosed pursuant to any relevant privacy laws or other laws.
I Agree Yes No