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Thank you for taking the time to complete this form.  A customer service representative will be in touch in the next couple of business days to provide you will your quote.   No coverage will be put in force without a fully completed and signed application.
Personal Info
First Name
Last Name
Daytime Phone Number
Evening Phone Number
Applicant`s Date of Birth
Co-Applicant`s Date of Birth
Home Details
Distance to Responding Firehall
Within 300 meters of a Hydrant?
Year Built
Type of Home
Square Footage (not including basement)
Basement Square Footage
What Percentage of Your Basement is Finished?
Square Footage of Addition (If applicable)
Basement Under the Addition?
Construction Type
Construction Quality
Physical Shape
Primary Exterior Finish(s)
Primary Roof Material
Number of Full Bathrooms
Number of Half Bathrooms
Attached Garage
Rooms Above the Garage?
Deck Square Footage (if applicable)
Porch Square Footage
Breezeway Square Footage (if applicable)
Wood Stove
Hot Tub
Any Other Special Features
Additional Rating Information
Any smokers Live in the Home?
Alarm System
Do you have a Mortgage?
How long have you had continuous habitational insurance?
When was your last claim?
What Form of Coverage do you want?
Deductible Amount
Sewer Backup Coverage Limit
Other Coverage or Comments
Please indicate any of the following items that you would like additional information about, or that you may need additional coverage on.

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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