ITV -- Insurance to Value Questionnaire

Property/Owner Information

Last Name(s):

First Name(s):

Mailing Address:

City:

Province:

Postal Code:

Home Phone:

Cell:

Work Phone:

Daytime Phone:

Email Address:

Preferred method of contact:

Dwelling Information (if different from above)

Location Address:

City:

Province:

Postal Code:

Information

Year Built:

Is the home located within 1000 feet of a fire hydrant?:

How far is the dwelling located from the responding firehall?: km

Name of responding firehall:

Single family owner occupied:

If there are any apartments or businesses in the dwelling, please describe.:

Type of Structure:

Exterior:

If exterior is other, please specify:

Area of Deck or Patio: square feet

Type of Deck or Patio:

If type of deck is other, please specify:

Area of Open Porch: square feet

Area of Enclosed Porch: square feet

Roofing:

If roof type is other, please specify:

Roofing: Year updated:

Garage: Size:

Garage: Type:

Number of Stories:

1 -- The living area of this type of residence is confined to the ground floor. The headroom in the attic is usually too low to be used as living area.
1.5 -- The living area in the upper residence is 50% to 90% of the ground floor. The upper level has a peaked roof and/or dormers. The living area of the residence is the sum of the ground floor plus the area on the second level with a ceiling height of 6 feet or more.
2 -- In this type of residence the second floor area is equal to or nearly equal to the ground floor area. The total living area is the sum of the ground floor area and upper floor area.
2.5 -- This type of residence has two levels of equal or nearly equal area and a third level which has living area approximately 50% of the first floor area, with a ceiling height of 6 feet. The total living area is the sum of the ground floor area, second floor area and area on the third floor with a ceiling height of 6 feet or more.
Bi-level or Split-Entry -- This type of residence has two floors of living area, one above the other. One area is about 4 feet below grade and the second is about 4 feet above grade. Both areas are approximately equal in size. Both levels have full ceiling heights. The living area is the sum of the lower level area and the upper level area.
Tri-Level -- This type of residence has three levels of living area, one at grade, one about 4 feet below grade and one about 4 feet above grade level. All levels are originally designed to serve as living areas. All levels have full ceiling heights. The living area is the sum of the area of the three levels.

Exterior Size: Length: feet

Exterior Size: Width: feet

Area of Finished Attic: square feet

Area of Sunroom/Solarium: square feet

Foundation: Type:

In a tri-level home, the foundation is the area beneath grade level.

If foundation is other, please specify:

Foundation Material:

In a 1, 1.5, 2, 2.5 storey or tri-level home: Percentage of Basement that is finished as living area: %

In a bi-level/split-entry home, Percentage of lower level that is finished as living area: %

If flooring is other, please describe:

Swimming Pool:

Swimming Pool Liner:

Area of Swimming Pool: square feet

Central Air Conditioning:

Plumbing: Year Updated:

Primary Source of Heat:

If other, please describe:

Age of Furnace (if applicable):

Age of Oil Tank (if applicable):

Placement of Oil Tank (if applicable):

How many of cords of wood do you burn per year? (if applicable):

Was your wood/pellet stove installed by a WETT certified technician? (if applicable):

Name of Installer:

Secondary Source of Heat:

Age of Furnace (if applicable):

Age of Oil Tank (if applicable):

Placement of Oil Tank (if applicable):

How many of cords of wood do you burn per year? (if applicable):

Was your wood/pellet stove installed by a WETT certified technician? (if applicable):

Name of Installer:

Chimney:

Number of Flues:

Wiring: Amps:

Type of Amp Service:

Type of Wiring:

If other, please describe:

Year updated and work completed when last updated:

Miscellaneous:

	Yes	No
Central Vac System
Air Exchanger
Monitored Burglar Alarm
Monitored Fire Alarm
Whirlpool Bath
Hot Tub
Sliding Patio Doors
Exterior French/Garden Doors
Bay/Bow Window
Fixed Picture Window

Number of Skylights:

% Cathedral Ceiling:

If you have a Palladian Window, what is its size?:

Claims (for new clients only)

Please list all losses sustained within the last 3 years for which claims have been made, including date of loss, cause and $ amount of claim:

	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%
Hardwood
Ceramic
Carpet
Vinyl
Laminate
Other

	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%
Copper & Plastic
Galvanized Steel
Cast Iron

	1	2	3	4	5	6
Full
Half
Ensuite