Home Insurance Application Form

Condition Removal Date YYYY-MM-DD (if new purchase)

Effective Date Insurance is Required YYYY-MM-DD (required)

How did you hear about us?

Owner Information

First Name (required)

Last Name (required)

Phone (required)

Your Email (required)

Birthdate YYYY-MM-DD (required)

On Title (required)
YesNo

Secondary Applicant Information

First Name

Last Name

Birthdate YYYY-MM-DD

On Title
YesNo

Current Insurance Company (Home/Tenants/Condo)

Current Insurance Policy #

Current Insurance Policy Expiry Date YYYY-MM-DD

Mortgagee Institution

Mortgagee Address

Previous Address in Past 3 Years

Have you had any claims in the past 5 years (list details)

Have you ever been cancelled, refused, or denied insurance?

YesNo

Years Continuously insured (no gaps)

Years Claims Free

If a new primary residence, will you occupy within 30 days?

YesNo

How long have your owned or occupied this property?

Occupancy of this location (required)

PrimaryRentalSeasonalVacantNew Build

Is there an alarm system? (required)

No AlarmLocal Alarm24 hr Central Monitored AlarmFor FireFor Burglary

Fire Hydrant within 300 meters? (required)
YesNo

Fire Hall within 8 km? (required)
YesNo

Detached Outbuildings(include type, size, value, siding, roofing, year built, quality):

Will there be any roommates or boarders? (required)
YesNo

Will there be any business on premises? (required)
YesNo

Are there any suites in the home? (required)
YesNo

Will there be any home sharing rentals? (required)
YesNo

Will there be any marijuana grown on premises? (required)
YesNo

Would you like to include Earthquake? (required)
YesNo

Would you like to say yes to credit score discount? (required)
YesNo

Would you like to pay in full or monthly? (required)
FullMonthly

Any extensions of liability/scheduled items to add (bikes/jewellery/business property) (required)

Dwelling Information

Architecture Style (required)

Construction Type (required)

Construction Quality (required)

Physical Shape (required)

Primary Exterior Siding (required)

Primary Roof (required)

Bathrooms

Description of Locale (required)

Has the home been completely gutted in the last 40 years?

Historic Registry

Garage

Carport

Porch

Deck

Additional Areas

Other

Electrical Upgrades

Plumbing Upgrades

Roofing Upgrades

Heating Upgrades

Hot Water Tank Upgrades

Municipal Sewer/ Septic

Sewer Back Up Valve

If using wood heat, how many chords are burned /year

If using wood heat, is your unit CSA approved and WETT inspected (copy of WETT required)