Bentley Insurance: Request an Property Quote

Request for Information

Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

All fields marked with a * are required.

Application Information:

First Name: *

Last Name: *

Street Address:

City:

Province: *

Postal Code: *

Email Address: *

Phone Number: *

Age: *

D.O.B of co-applicant : *

Do you have a mortgage? *	Yes No
Are you a Smoker? *	Yes No
How long continuous home insurance? *
Years, claims free? *
Number of Storeys *
Year home built *
Sq Ft excluding basement*
Age of Roof *
If over 15 years old, when was the roof replaced? *
Material roof is made of: *
Furnace - last replaced when? *
Plumbing *	Copper Plastic
Electrical *	60 AMP 100 AMP 200 AMP
Ceilings *	8 Ft 9 Ft Cathedral
Basement finished? *	Yes No
Exterior Walls % material made of *
Garage: *
How many car garage: *
Open Porch (sq ft) *
Closed porch (sq ft) *
Deck (sq ft) *
Interior Partitions % drywall or plaster *
Ceilings % drywall or plaster *
Wall coverings % paint, wallpaper, paneling *
Bathroom - Full bath (3 fixtures) qty *
Bathroom - Ensuite bath (4 fixtures) qty*
Bathroom - Half Bath (2 fixtures) qty *
Flooring - type of material % wise for entire house *
Fireplace *
How Many Fireplaces? *
Central Air Conditioning - same ducts or seperate ducts? *
Radient Floor Heating? *	Yes No

Additional Features:
If you have any additional features such as central vacuum system, interior sprinkler system, central burglar alarm system, central fire alarm system, please include here.

Comments:

How do you wish to be contacted? By Phone By Email