Tenant Insurance Application

Name*:

Phone*:

Date of birth*:

Email:

Additional Members:

Name:

Phone:

Date of birth:

Email:

Name:

Phone:

Date of birth:

Email:

Name:

Phone:

Date of birth:

Email:

Address*:

Mailing Address (if different):

Additional Named Insured:

How did you hear about us?

Are you within 150m or 300m of a fire hydrant:

YesNo

Are you within 5km or 8km of a fire hall:

YesNo

Previous Address Information

Previous Address:

How many years have you resided at this address:

Other Information

Move in Date (if applicable):

Credit Consent: YesNo

If yes: VerbalWritten

Personal Property Limit

Contents Limit for Personal Property: $

Previous Insurance History

Insurance Company Name:

Policy Number:

Effective Date:

Expiry Date:

Have you had any claims in the last 5-10 years: YesNo

If yes, details:

Any claims that you are aware of at the new location: YesNo

If yes, details:

Have you ever been cancelled or refused insurance: YesNo

If yes, details:

Home Details

Style of your home (1 story, 2 story, bi-level, condo):

Type of Home (detached, semi-detached):

Year home was built:

Sq. ft. Total Living Area:

Type of Exterior Siding:

Number of kitchens:

Number of bathrooms:

Number of smoke detectors:

Garage or Carport: NoneGarageCarport

Number of cars (if applicable):

Type: AttachedBuilt-in

Is there a basement or crawlspace: YesNo

Type: FinishedUnfinished

Heating

Primary Heat Type:

Central Furnace: YesNo

Central Furnace type: Natural GasElectricPropaneWoodOil

Heat: BaseboardsCeiling RadiantIn-floor radiantWood stoveWood insertPellet stove

If wood-stove/insert # of cords burned annually:

Year Primary heat was updated:

Auxiliary Heat (if applicable):

Type: Wood-stoveWood InsertPellet Stove

If wood-stove/insert # of cords burned annually:

How often is chimney cleaned:

Professionally Installed:
yesNo

WETT certified:
YesNo

Year auxiliary heat was updated:

Oil Tank (if applicable)

Location:

InsideOutsideIn groundAbove ground

Tank Information:

Single wallDouble wall

Year manufactured:

Dwelling Construction

Type: Wood frameConcreteLogPanabodeSteel

Plumbing

Type: CopperPolybutylene (poly8)GalvanizedPEXPVCOther, please describe

Describe Other if selected

Hot Water: TankOn demand

Hot water tank age:

Does the home have a boiler? YesNo

Year of any plumbing updates:

Sewer: SepticCity sewer

Roof

Roof Type: Asphalt ShinglesClay tileAluminumTar and gravelSteelTorch on membraneWood shake

Year of Roof Update:

Electrical

CopperAluminumKnob and tube

Other:

BreakersFuses

Amps: 60 amp100 amp200 amp

Other:

Year of any updates to electrical:

Additional Questions

Is the dwelling under construction / renovations? YesNo

If yes, provide additional information:

Number of families living in the home:

Any: Rental suitesRoommatesBordersStudents

If yes, provide additional information:

Miscellaneous

Pool: YesNo

If yes: In groundAbove ground

Hot tub: YesNo

Trampoline: YesNo

Number of cannabis plants grown on premises:

Does the dwelling have any of the following:

Security: Monitored Burglary AlarmIntercomBlock WatchWalled CommunityDead Bolt Locks24hr Video SystemSecured EntranceSecurity Guard

Earthquake coverage required? YesNo

Fire: Fire AlarmSprinkler System

Number of fire extinguishers:

Home Base Business: YesNo

Name of business:

Type of business:

Clients visit home: YesNo

Do you have a current CGL: YesNo

Website: