Personal Info
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| First Name |
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| Last Name |
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| Address |
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| Daytime Phone Number |
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| Evening Phone Number |
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| Email |
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| Applicant`s Date of Birth |
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| Co-Applicant`s Date of Birth |
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Home Details
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| Distance to Responding Firehall |
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| Within 300 meters of a Hydrant? |
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| Year Built |
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| Type of Home |
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| Square Footage (not including basement) |
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| Basement Square Footage |
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| What Percentage of Your Basement is Finished? |
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| Square Footage of Addition (If applicable) |
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| Basement Under the Addition? |
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| Construction Type |
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| Notes |
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| Construction Quality |
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| Physical Shape |
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| Primary Exterior Finish(s) |
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| Primary Roof Material |
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| Number of Full Bathrooms |
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| Number of Half Bathrooms |
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| Attached Garage |
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| Rooms Above the Garage? |
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| Deck Square Footage (if applicable) |
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| Porch |
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| Porch Square Footage |
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| Breezeway Square Footage (if applicable) |
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| Wood Stove |
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| Hot Tub |
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| Any Other Special Features |
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Additional Rating Information
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| Any smokers Live in the Home? |
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| Alarm System |
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| Do you have a Mortgage? |
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| How long have you had continuous habitational insurance? |
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| When was your last claim? |
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| What Form of Coverage do you want? |
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| Deductible Amount |
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| Sewer Backup Coverage Limit |
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| Other Coverage or Comments |
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| Please indicate any of the following items that you would like additional information about, or that you may need additional coverage on. |
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| Privacy Terms |
| By sending this information, I understand that Village Insurance Brokers or any insurer, to whom Village Insurance Brokers submit my application may collect, use and disclose personal information from me and about me for the following purposes: 1) To understand my needs. 2) To analyze the suitability of my insurance and financial services for me. 3) To determine my eligibility for products and services. 4) To set up, manage and offer products and services that meet my needs. 5) To provide me with ongoing service. 6) To meet legal and regulatory requirements. 7) To facilitate underwriting my insurable risks and insurance claims. Withdrawal of Consent: You may generally withdraw your consent at any time. If you refuse or withdraw your consent to the collection, use or disclosure of information about you, we may not be able to provide or continue to provide you with some products, services or information of value to you. |
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