Casey Home Owners Insurance Quote Sheet

DWELLING DESCRIPTION

Property Address:

Original Year Building:

Structure Type: Detached Townhouse Basement Suite Semi Detached Apartment Other

If "Other" Please Explain:


Number of Apartments in Building:

Is There a Co-Occupant Who Requires Coverage: Yes No

Fireplace: Yes No Wood Burning Stove: Yes No

Distance to Fire Hydrant: Distance to Fire Hall:


Coverages Desired:

Type: Comprehensive (All Risks) Named Perils

Deductible: $500 $1000

Liability: $1 000 000 $2 000 000

Sewer Back-up: Yes No

Value of Contents:

Additional Coverages: Jewelry Fine Arts Sporting Equipment Other

If "Other" Please List Items and Their Value:


Name:

Email:

Phone: FAX:



PLEASE NOTE:
This is only a quote and does not constitute a formal application, nor does it bind the agent or the applicant.