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GENERAL INFORMATION

Name*

Prefix First Last

Daytime Phone*

Email*

Property Location

Address*

Street Address Address Line 2 City Province Postal Code

POLICY INFORMATION

Type of Policy*

Home

Condo

Tenant

Currently Insured*

Yes

Renewal Date or Date Last Insured*

MM slash DD slash YYYY

How many years consecutively insured:*

Was your last policy cancelled by the insurance company?*

Yes

If yes, please provide details:

Was your last policy cancelled due to non-payment?*

Yes

How many cancellations due to non-payment in the past 3 years?

Coverage:

Liability:*

$1,000,000

$2,000,000

Deductible:*

$500

$1000

Sewer Backup Coverage Required?*

Yes

Claims

Did you make any insurance claims within the past 5 years?*

Yes

List all claims in the past 5 years:*

Date

Type

POLICY HOLDER INFORMATION

Owner's Date of Birth*

Spouse's Date of Birth

Are all residents of the household non-smokers?*

Yes

Monitored Alarm System:*

Yes

Alarm alerts for:

Check all that apply.

Intrusion

Fire

Smoke

CO2

Number of Smoke Detectors*

Dead Bolt Locks on all doors*

Yes

Distance to Nearest Fire Station*

Distance to Closest Fire Hydrant*

HOMEOWNERS

Year Dwelling Built*

Current Dwelling/Building Value (or purchase price if new):*

Mortgage*

Yes

Owner Occupied*

Yes

Occupied Since*

Number of Families*

Number of Units*

Number of Storeys*

Pool*

Yes

If building is older than 20 years, please provide dates (or approx dates) when the following were last updated:

Plumbing

Primary Heating

Roof

Wiring

This field is for validation purposes and should be left unchanged.

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