Home Insurance Application

Client Details

Client 1

Full Legal Name

Date of Birth (MM/DD/YYYY)

Phone Number

Email Address

Client 2

Full Legal Name

Date of Birth (MM/DD/YYYY)

Phone Number

Email Address

Client 3

Full Legal Name

Date of Birth (MM/DD/YYYY)

Phone Number

Email Address

Client 4

Full Legal Name

Date of Birth (MM/DD/YYYY)

Phone Number

Email Address

Location Address:

Mailing address: (If different)

Additional Named Insured: (ANI)

Previous Address (If resided at current residence for less than 3 years)

Previous Address:

How many years you resided at this address:

Previous Insurance History

Insurer Name:

Policy #:

Effective Date (MM/DD/YYYY):

Expiry Date (MM/DD/YYYY):

Any Claims in the last 5 years?
YesNo
If yes, provide details

Any Claims that you are aware of at the new location?
YesNo
If yes, provide details

Have you ever been cancelled. refused, or declined insurance?
YesNo
If yes, provide details

*If Applicable

Effective Date

Subject Closing Date

Possession Date

Move in Date

Vacant: YesNo
If yes, provide additional details

How long has it been vacant?

How long do you expect it to be vacant?

Insured Since:

Insured w/Broker Since:

Property Insured Since:

Occupied Since:

Mortgage / Credit Consent

Mortgage: YesNo
Credit Consent: YesNo verbalwritten
Number of mortgages and/or secured lines of credit:

Name of financial institution

House Details

Style of home (1 story, 2 story, bi-level):
Type of home (detached, semi-):
Year built:
Sq. ft. per floor:
Type of exterior siding:
Is there a basement or crawl space:
FinishedUnfinished
Any decks or porches (sizes in sq. feet):
Any custom features:
Any detached structures (please list):
[text]
Number of kitchens:
Number of bathrooms:
Number of smoke detectors:
Number of fire extinguishers:
Monitored burglary alarm:
YesNo
Number of cars:
Garage or carport: Built inAttached

Roof

Roof Type
Asphalt ShinglesClay tileAluminumTar and gravelSteelTorch on membraneWood shake
Year of Roof Update:

Dwelling Construction Type

Wood frameConcreteLogPanabodeSteel

Fire Protection

Within 300m of a fire hydrant: YesNo
Within 8km of responding fire hall: YesNo

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 Type (if applicable):
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:

Electrical

CopperAluminumKnob and tube
Other:
BreakersFuses
Amps: 60 amp100 amp200 amp
Other:
Year of any updates to electrical:

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

Water Prevention Sump pump and/or Back flow valve

Sump pump: YesNo
Aux. power: PedestalSubmersibleFloor suckerWater poweredNoneGenerator
Back flow valve: YesNo
If yes: GateFlapper

Additional Questions

Is the dwelling under construction / renovations? YesNo
If yes, provide additional information:
Vacant: YesNo
If yes, provide additional details

How long has it been vacant?

How long do you expect it to be vacant?

Number of families living in the home:

Any:
Rental suitesRoommatesBordersStudents
If yes, provide additional information:

Rental Income $:
Landlord contents $:

Home Base Business: YesNo

Name of business:
Type of business:
Clients visit home: YesNo
Do you have a current CGL: YesNo
Website:
Any farming on premises YesNo

Other

Pool: YesNo
If yes: In groundAbove ground
Hot tub: YesNo
Trampoline: YesNo
Dock and/or Wharf: YesNo
Earthquake coverage required: YesNo
Number of cannabis plants grown on premises:

Please note: Coverage is not considered bound until you have received confirmation from a licensed broker.

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