MONKMAN INSURANCE SERVICES
Personal Insurance


Fill out the form below, and click "Submit Form" and someone from Monkman Insurance will respond within one business day.  You can also print this form, fill it out and fax it to
705-743-1996 ... whichever is more convenient for you.

If you do not feel comfortable filling out the online application, please email your name and phone number and a representative will be in contact with you to discuss your needs.


Auto Insurance Quote
We find that in today's market, in order to provide you with an accurate quotation for automobile insurance and the best coverage, we require that you book an appointment to come in to discuss your needs.



Home Insurance Quote
Personal Information
First Name
Last Name
Email Address
Address 1
Building Address (if different than mailing)
City
Postal Code
Telephone Number Ext.
Employer (Optional)
Position Held (Optional)
Date of Birth MM/DD/YY
Currently Insured Yes No   If yes, how many years?                         Present Insurer                                         Expiry Date:
Claims History Give details of any claims in the last 5 years:
Home Information
Age of dwelling
Year updated (if over 20 years old) Heat
Electrical
Plumbing
Roof
Number of Families in dwelling
Retired Yes No
Smoke Free Yes No
No. of smoke detectors in dwelling
Fire Extinguishers Yes No
Fire Protection Fire hydrants Located within 300 metres of swelling
Dwelling located within 8 km of Fire Hall
Located beyond 8 km but within 13 kn of Fire Hall
Located beyond 13 kn of Fire Hall
Current Insured

 Value of dwelling
If no current insurance, the approximate value of unit.


Other Do you have a mortgage?  Yes No

Has any insurance company cancelled, declined or refused to renew or issue property insurance in the last 5 years?  Yes No         If yes, give details:

Please describe any watercraft or valuable items that need to be added to your policy:

Construction material Fire Resistive Masonry
Brick Veneer Frame
Heating Furnace - central
Electric
Hot water/steam
Approved combination furnace
Solid fuel
Space heaters
Wood burning stove
Fireplace
Fireplace insert
Solar
Other
Alarm Fire Alarm Yes No
Local Alarm  Monitored Alarm
Intrusion Alarm Yes No
Comments

Monkman Insurance & Financial Services
243 Hunter St. W.   P.O. Box 626   Peterborough, ON   K9J 6X8
Bus: (705) 743-8721  Fax: 743-1996
Toll Free # 1-877-870-1901
email: info@monkmaninsurance.com