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Name
Address (include windows normally left unlocked)	ST, PROV, POST
Phone # Home Work	(123) 456-7890
Email

Property Insurance Quote
Date of Birth (for astrological blackmail)	YYYY/MM/DD
Do you have a lot of money? If a lot, please provide credit card number and expiry date	yes no YYYY/MM/DD
Favorite Hockey Player
Career Span	to YYYY/MM/DD
Have you ever been cancelled by an insurance company? If yes, would you like me to kill them all?	yes no
What Year Was Your House Built?	YYYY
Construction (Frame, Brick, Stick, Hay)
Within 300 Metres of a Friendly Neighbor?	yes no
How many kilometres to a police station?
What is your blood type?
How Many Knives in the House?	0 1 2 3 4 5
Current Insured Value
Current Deductible
Would you like to join me in holy matrimony before I come to your house? (I love you and everything) (for discount purposes)
Please specify if you have roomers, borders, home offices etc. in the dwelling. Also, if you need any further coverage for boats, motors, jewellry etc., please provide length of boat, make/model/serial number and value for each.