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Homeowners Renewal Questionnaire


By taking a few minutes to fill out and return this brief checklist, your nation West agent can help make sure that your insurance coverage is up-to-date and complete. Information submitted will be help confidential and will be used for renewal purposes only. Submission of information does not obligate you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
Province
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
E-Mail Address
Required
Policy Information
Have you made any upgrades or additions to your home in the last year?
Required
If yes, please provide details
Optional
Please advise the age of the following
Roof
Required
Hot Water Tank
Required
Furnace
Required
Please advise the approximate date your furnace was last serviced
Required
Have you started a business out of your home?
Required
If yes, please provide details
Optional
Have you installed a woodstove in your home?
Required
Have you added, changed or paid off a mortgage holder in the last year?
Required
Has an alarm system (local or monitored) been installed in the last year?
Required
Are you a non-smoking household?
Required
If you have lived at your current address for more than 5 years, you may qualify for a stability discount. Please confirm your move-in year.
Required
How many families are living in your home?
Required
Do you rent out rooms to boarders?
Required
Would you like a quote on higher limits or liability? Limits up to $5Million are available.
Required
***Did you know that Sewer Back-up Coverage is only available to add or increase when your policy is new or renewing? Please contact our office if you would like to discuss adding or increasing Sewer Back-up Coverage.
**Did you know that most insurance companies insure your jewelry up to $6,000.00 (subject to your deductible)? If your jewelry exceeds this amount, you may want to call us to discuss your options.
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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