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506-635-1515 huestis@huestis.ca
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Home Insurance - Request a Quote
PERSONAL INFORMATION
* First name
* Last name
Date of Birth
MM DD YY

Premises address
  
* No. and street
Apartment no.
* City
* Province
* Postal code
* Telephone number - Home
Telephone number - Office   ext. 
Fax
E-mail
Occupation
Receive your estimation by?
E-mail  Telephone   Fax  Mail 
 
* Denotes required Information
CURRENT COVERAGE AMOUNTS
Is this a log home?
Yes  No 
Building
 $
Contents
 $
  (Personal Liability of $1,000,000 is included in the proposal)
Is sewer back-up coverage required?
Yes  No 
Are there currently any scheduled items such as jewellery, cameras, computers, electronic equipment?
Yes  No 
Year Built
Mortgage
Yes  No 
Years consecutively insured
 Years
Present Insurer
If no previous insurance, Is this your First Home?
Yes  No 
Has any insurance company cancelled, declined, or refused to renew property insurance in the past three years?
Yes  No 
HEATING
 Primary Source of Heat
 Secondary Source of Heat
If wood, how many cords?
If there is an oil furnace, how old is the oil tank?
SWIMMING POOL
Do you have a Swimming Pool?
Yes  No 
MISCELLANEOUS
Burglar Alarm
Yes  No 
Is your Burglar Alarm monitored?
Yes  No 
Smoke Detectors
GENERAL
Fire Hydrant Protected?
Yes  No 
How far is dwelling located from responding Fire Hall
 Km
Occupancy:Single family owner Occupied
Yes  No 
Any Apts. or Business located in the home?
Yes  No 
If the dwelling is over 25 years old, describe updating with respect to:
Wiring Year Updated
Heating Year Updated
Plumbing Year Updated
Roofing Year Updated
Please list all losses sustained within the last 10 years for which claims have been made
  
Year of Loss
Cause
Amount of Claim
 $
Year of Loss
Cause
Amount of Claim
 $
  * If more than two (2) losses, please include in comment section below.
Comments/Addtional Information
  Please be advised that should you choose to move forward with a policy through our company, a replacement cost evaluation form must be completed to determine the replacement value of your dwelling and coverage amount will be based accordingly.
 
   
"Big enough to serve you. Small enough to care."

11 Lloyd Street, Saint John, NB E2M 4N4
phone: (506) 635-1515 fax: (506) 635-0747 email: huestis@huestis.ca