Winnipeg Insurance Brokers Ltd.

In order for us to provide you with an insurance quote, we need to know some information. Please fill out this questionaire to the best of your knowledge. We will get back to you with a quote as soon as possible.

Please fill in the below fields

Name:

Address:

City:
Province
Phone:

Postal Code

E-mail Address:

Information required by us regarding your home.

Main Floor Approx. Size (Sq. Feet):	Year Home was built:
Number of stories:	Number of Bathrooms: Full Baths: Half Baths:
Finished Attic: Yes No	If Yes Sq. ft.
Basement: Yes No	Fireplace: Yes No
Finished Basement: Yes No	If Yes Sq. ft.
Porch / Deck: Yes No	If Yes Sq. ft.
Central Air Conditioning Yes No
Garage or Carport: Yes No	If Yes select one:
Solarium / Sunroom: Yes No	If Yes Sq. ft.
Swimming Pool: Yes No	If Yes select:

Built ins: Garage Door Opener Electronic Air Cleaner Central Vacuum Dishwasher	Counter Top Range Oven Wet bar Sauna Other
Wood Burning Stove Yes No	Structure Type:
Heating:	Construction:

Homes over 20 years old, please indicate when the following were last updated.

Electrical: Year Circuit Breakers: Year Fuses: Year

Heating: Year Plumbing: Year Roof: Year

Claims: Any claims in the past three years:Yes No
If Yes , describe: (Date, type of loss, amount paid)

For discount purposes:
Age of home owner:
Burglar alarm: Local Central Station Monitored

Neighbourhood Watch: Yes No
If Yes : name of Block Captain