Name: Address: City/Town: Postal Code: Type of residence: Apartment Condo House Other If House: Townhouse Row House Detached Semi-Detached Building: Owned Rented Date Occupied by You: Loss Payee (Mortgagee): (name & address) Current Building Value: $ Year Built: If over 25 yrs old, year last update of: Plumbing: Heating: Roof: Electrical: Number of Stories: Alarm System?: Yes No Monitored?: Yes No Ground Floor Sq. Footage: Attached Garage?: Yes No Construction: Brick Wood Frame Other If other, indicate construction: Fire Hydrant within 300m?: Yes No Fire Hall within 8km?: Yes No # of full 3 pc Bathrooms: Finished Basement?: Yes No Scheduled Items Desired: Jewelery Yes No Value $ Fine Arts Yes No Value $ Cameras Yes No Value $ Silverware Yes No Value $ Other Value $ Comments: How would you prefer to be contacted? By Phone Fax Email What time is best? Morning Afternoon Evening Where? Work Home Work Phone: Home Phone: EMail: