– Neepawa Insurance – Investment Broker – Real Estate Agents – Travel Agency – Neepawa, McCreary, Manitoba | Home Insurance Quote

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Neepawa & McCreary / Toll Free: 1 877-476-2345

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Applicant Information

Last Name:

First Name:

Birth Date:

Last Name:

First Name:

Birth Date:

Box Number:

Street Address:

City:

Postal Code:

Phone #:

Email:

Insurance History

Previous Insurance:

Policy #:

Previous Insurance Start Date:

Previous Insurance Expiry Date:

Claims in past 5 years? If so, explain:

Ever refused insurance/cancelled? If so, explain:

House Information

Effective Date:

Year Built:

Square Footage:

Style of Home:

Construction Type:

Physical Shape:

Siding:

Full Baths:

Half Baths:

Garage: YesNo

Square Footage:

Year Built:

Porch: YesNo

Square Footage:

Year Built:

Deck: YesNo

Square Footage:

Year Built:

Basement: YesNo

Finished SQ ft:

Unfinished SQ ft:

Attic: FinishedUnfinished

Square Footage:

Year Built:

Additions:

Square Footage:

Year Built:

Updates

PLUMBING

Copper:

%

PVC:

%

Galvanized:

%

Cast Iron:

%

Year:

HEATING

Gas: yesno
Wood: yesno
Electrical: yesno
F/A: yesno
BB:yesno
Year:

ELECTRICAL

AMP: yesno
Aluminium: yesno
Copper: yesno
Breakers/Fuses?: yesno
Knob & Tube: yesno
Year:

SHINGLES

Type of Roofing:

Additional Information

Mortgage: YesNo

Address:

City/PC:

Lawyer:

Hydrant Protected? YesNo

Distance to Fire Hall:

Acreage? How many acres?:

Any Farm Animals?:

Other Farm Exposures: YesNo

Boarders: YesNo

How Many:

Separate Suite?: YesNo

Family or Individuals:

Notes:

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Contact

NEEPAWA:

371 Mountain Avenue
Box 969
Neepawa, MB. R0J 1H0

Phone: (204) 476-2345
Fax: (204) 476-2814
E-Mail: office@gillandschmall.com

McCREARY:

436 Second Ave
Box 59
McCreary, MB. R0J 1B0

Phone: (204) 835-2501
Fax: (204) 835-2732
E-mail: mccrearyoffice@gillandschmall.com

OFFICE HOURS:

Mon – Fri | 8:00 to 5:30
Saturday | 9:00 to 4:00
Closed Statutory Holidays

McCreary Hours

Mon-Fri | 9:00 to 5:00

Closed Weekends and Statutory Holidays