RIVERS OFFICE: MON - FRI: 9:00 TO 5:00 (CLOSED 12-1pm) SAT: 9:00 TO 12:00
201 MAIN ST. RIVERS, MB (204) 328-5264
OAK RIVER OFFICE: TUES - FRI: 10:00 TO 3:00
16 COCHRANE ST. OAK RIVER, MB (204) 566-2490
Fill out the form to start your insurance quote.
Last Name *:
First Name *:
Birth Date:
Last Name:
First Name:
Box Number:
Street Address:
City:
Postal Code:
Phone #:
Email *:
Previous Insurance:
Policy #:
Previous Insurance Start Date:
Previous Insurance Expiry Date:
Claims in past 5 years? If so, explain:
Ever refused insurance/cancelled? If so, explain:
Effective Date:
Year Built:
Square Footage:
Style of Home:
Construction Type:
Physical Shape:
Siding:
Full Baths:
Half Baths:
Garage:YesNo
Porch:YesNo
Deck:YesNo
Basement:YesNo
Finished SQ ft:
Unfinished SQ ft:
Attic:FinishedUnfinished
Additions:
Gas:YesNo Wood:YesNo Electrical:YesNo F/A:YesNo BB:YesNo Year:
AMP:YesNo Aluminium:YesNo Copper:YesNo Breakers/Fuses?:YesNo Knob & Tube:YesNo Year:
Copper:
%
PVC:
Galvanized:
Cast Iron:
Year:
Type of Roofing:
Mortgage:YesNo
Address:
City/PC:
Lawyer:
Hydrant Protected? YesNo
Distance to Fire Hall:
Acreage? How many acres?:
Any Farm Animals?:
Other Farm Exposures: YesNo
Boarders:YesNo
How Many:
Separate Suite?:YesNo
Family or Individuals:
Notes:
Reaxion Graphics