Home Owner's Insurance
  1. Please send us your information. We will respond to your request within the next 24 hours during business week.
  2. First Name(*)
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  3. Last Name(*)
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  4. Phone
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  5. Address(*)
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  6. City(*)
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  7. Province(*)
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  8. Postal Code(*)
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  9. Type of Residence(*)
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  10. Residence Use(*)
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  11. Date of Birth
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  12. Is the home jointly owned?(*)
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  13. What is your occupation(*)
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  14. Co-owner Information
  15. First Name
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  16. Last Name
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  17. Date of Birth
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  18. Purchase Date
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  19. Estimated Year Built
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  20. Type of Construction(*)
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  21. Type of Roof(*)
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  22. Number of Stories(*)
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  23. Full bathrooms(*)
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  24. Half bathrooms(*)
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  25. What is the total square footage of your home(*)
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  26. Basement
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  27. Deadbolt Locks
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  28. Smoke Detector
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  29. Fire Extinguisher
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  30. Monitored Fire Alarm
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  31. Burglar Alarm
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  32. Home Located Within 8 kilometres of a responding fire hall?
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  33. Home Located Within 1000 Feet Of A Fire Hydrant
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  34. Swimming Pool
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  35. Home Located Within City Limits
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  36. Do you currently have home insurance coverage?
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  37. Who is your insurance currently with
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  38. Have you ever had a policy cancelled by a company in the past five years?
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  39. When does your policy expire?
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  40. Coverage Amount
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  41. What is your annual premium
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  42. Are you currently receiving any discounts
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  43. Deductible Desired
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  44. Amount Of Liability Coverage
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  45. Earthquake Coverage Desired?
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  46. Number of Homeowner's Claims(*)
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  47. Jewelry And Watches $
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  48. Silver$
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  49. Guns $
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  50. Furs $
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  51. Stamp And Coin Collection $
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  52. Would you like to see if we can save you more money by bundling any of the following policies?
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  53. Fine Arts And Breakable Items $
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  54. Please give any additional comments you feel appropriate for this quotation.
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  55. Current email address(*)
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  56. Current Email Address Again(*)
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  57. Submit this Form
      
 

DeHart & Stauffer Insurance Brokers Copyright © 2014. All rights reserved.
843 King Street WestOshawa, Ontario L1J 2L4 (905) 576-2234Fax 1-253-550-4655