Hodges & Company Insurance Services - BC Canada - auto, home, life, business, travel insurance and more

Homeowners Insurance for Single or Multiple Family dwelling
Address of your home:
City:
Postal Code:
Is your house located with in 1000 feet (300 Metres) of a fire hydrant	Yes No
Is there a rental suite in your house	Yes No
Do you operate or conduct any business from your home	Yes No
	If yes please describe details
Is there any wood heating in your home other than a fireplace	Yes No
	If yes please describe
Year dwelling built:
Replacement cost of Dwelling:
Liability Limit:	1 Million 2 Million
Owners / Occupant Age Discount:
Owner Occupied:	Yes No
Mortgage Free:	Yes No
Alarm Discount:
Are you a member of Neighbourhood Watch or Block Watch	Yes No
Have you had any losses in the past 3 years?	Yes No
	If yes, Please explain (type of loss, date)
Do you currently carry insurance	Yes No
If yes, when does it Expire?
What was the name of your last insurance company
Have you been insured within the past 30 days	Yes No
How many years have you carried continuous coverage?
How would you like us to provide this quote?	Phone Fax E-mail
First Name:
Last Name:
Phone Number:
Fax Number:
Email Address:
Questions / Comments