Cottage Quote Org

Cottage Form Request

We please ask that you fill in all fields in the questionnaire. If you don't know the information at the time of completing questionnarie. Please enter N/A

Property Owner Information

Property owner: *

Date of birth: *

Co-occupant/owner:

Date of birth:

If there are multiple owners of the cottage, list names & dates of birth for all owners.

Other Owners:

Date of birth:

How did you hear about us?

ie.. Friend, internet, yellow pages, etc..

Home Address: *

City: *

Province *

Postal Code: *

Home phone# *

Work phone#

Mobile#

Email address *

Cottage address/location
(include postal code & nearest town)

Street Address *

City (or nearest town) *

Province *

Postal Code *

How long have you owned the cottage *

If New purchase, provide closing date:

Do you occupy the cottage at least once every 30 days throughout the year: *

Yes

Do you occupy the cottage at least once every 60 days throughout the year: *

Yes

Is the cottage winterized: *

Yes

Is the cottage under construction: *

Yes

Is there year round road access to the cottage: *

Yes

Water access only: *

Yes

Is the cottage located on an island: *

Yes

Distance to nearest responding firehall in KM's by roads open year round: *

Fire hydrant within 300 metres or 1000 feet *

Yes

Monitored alarm system. Indicate which ones if any. *

None

Fire

Burglar

Low temperature

Other alarms/security or indicate none. *

A copy of alarm certificate will be required

Is the cottage rented out: *

Yes

If Yes, please fill out the next field to the right.

If yes, how many weeks per year

Is the cottage rented through the use of a rental agency: *

Yes

N/A

If yes, what agency is looking after the rental

Are the owners & residents of the cottage: *

Smokers

Non-Smokers

Mortgage on Property: *

Yes

If yes, provide full name & address incl. postal code for mortgagee:

Current cottage insurer: *

Policy # *

Expiry date: *

Current home insurer: *

Policy# *

Expiry date: *

Have you had any claims on a personal property policy in the past 5 years: *

Yes

If yes, provide date, description and amount paid out:

Building info

Year built: *

Indicate construction: *

Frame

Log

other

If other, please provide contruction details in the box below.

Other construction:

Number of Stories:

Total living area sqft:

Excluding the Basement

Bathrooms:

Indicate the number of the bathrooms.

Basement/Foundation:

Basement

Crawlspace

Piers

If Basement, provide:

sqft Finished Basement:

sqft Unfinished Basement

Attached Structures

Garage # of vehicles:

If this field doesn't apply to you. Please type in N/A.

Deck sqft

If this field doesn't apply to you. Please type in N/A.

Screened Porch sqft

If this field doesn't apply to you. Please type in N/A.

Sunroom sqft

If this field doesn't apply to you. Please type in N/A.

Other

If this field doesn't apply to you. Please type in N/A.

Cottage Exterior: *

Wood Siding

Vinyl Siding

Brick Veneer

Log

Other

Photos of cottage will be required. You can upload image below

If Other, indicate exterior:

File upload

Browse...

Maximum size 10MB

Electrical Service: *

Breakers

Fuses

AMP: *

100

200

N/A

Year Upgraded: *

Plumbing: *

Copper/PVC

Galvanized/ Cast

Other

Year Upgraded: *

Roofing Material: *

Shingles

Metal

Other

If Other, indicate roofing Material:

Year Upgraded: *

Auxiliary heat: *

None

Woodstove

Fireplace insert

Traditional fireplace

Other

If Other, indicate Auxiliary heat:

If woodstove or insert, is the unit CSA, ULC or Warnock-Hersey approved: *

Yes

N/A

How old is the unit: *

If this field doesn't apply to you. Please type in N/A.

Make: *

If this field doesn't apply to you. Please type in N/A.

Professionally installed: *

Yes

N/A

Installation inspected by a WETT certified technician: *

Yes

N/A

Date inspected:

A solid fuel heating (woodstove) questionnaire and photo will be required.

Any business operation at cottage location: *

Yes

Describe Business Operations: *

If this field doesn't apply to you. Please type in N/A.

Detached structures located on the property: *

Yes

If yes, provide additional information, in the comment box below, itemizing all detached structures on the property in the box below (sheds, bunkies, boathouses, etc). Provide description, year built, size, replacement value, use, year the roof was upgraded and if the structure contains any services such as heating, electricity or plumbing describe each along with year upgraded for each of the services.

List deatched structures

example: Sheds - boathouses - bunkies

Watercraft: *

Yes

Any watercraft losses in past 5 years: *

Yes

N/A

If watercraft exists, provide additional information, in the comment box below, itemizing all watercraft, motors and trailers you own. For boats provide year, make, model, value, length, serial #. For motors provide year, make, model, value, horsepower. For trailers provide year, make, value, serial #. List maximum speed of each boat & motor is also required. Also, please provide a complete list of all operators including names, dates of births and years of experience.

Type the characters *

To the best of my knowledge, I declare that the information that I have given is true and correct. Please type in the code below and click send.

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Mason Insurance Brokers
P.O. Box 219, 317 King St.
Welland, Ontario, L3B 5P4
Toll-Free: 1-800-563-1641
Phone: 905-788-3535
Fax: 905-788-9202