Name*:

Phone*:

Date of birth*:

Email:

Additional Members:

#2 Name:

Phone:

Date of birth:

Email:

#3 Name:

Phone:

Date of birth:

Email:

#4 Name:

Phone:

Date of birth:

Email:

Location Address*:

Mailing Address (if different):

Name of Mobile Home Park (if applicable)

Additional Named Insured:

Union Member? YesNo

Previous Address Information

Previous Address:

How many years have you resided at this address:

Previous Insurance History

Insurer Name:

Policy Number:

Effective Date:

Expiry Date:

Have you had any claims in the last 5 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, refused or declined insurance: YesNo

If yes, details:

*If Applicable

Effective Date:

Subject Closing Date:

Possession Date:

Move in Date:

Insured Since:

Insured w/ Broker Since:

Property Insured Since:

Occupied Since:

Mortgage / Credit Consent

Credit Consent: YesNo

If yes: VerbalWritten

Mortgage: YesNo

Number of mortgages and/or secured lines of credit:

Name of financial institution:

Mobile Home/Manufactured Details

Year Built:

Manufacturer:

Model:

Serial Number:

Single Wide:YesNo

Double Wide:YesNo

Width:

Length:

Insured Value:

Purchase Price:

Content Value:

# of smoke detectors:

Garage: NoneAttachedBuilt-in

Type: GarageCarport

# of cars:

Any decks or porches:YesNo

If yes, Size:

Any additions:YesNo

If yes, Size:

Is it fully skirted:YesNo

Roof:Asphalt ShinglesClay TileAluminiumSteelWood ShakeTar and GravelTorch on Membrane

Year of Roof Update:

Any Custom Features:

Fire Protection

Are you within 300m of a fire hydrant:

YesNo

Are you within 8km of a responding fire hall:

YesNo

Heating

Primary Heat Type: —Please choose an option—Central furnaceBaseboardsCeiling radiantIn-floor radiantWoodstoveWood InsertPellet Stove

If Central Furnace, type: Natural GasElectricPropaneWoodOil

If woodstove or wood insert, # of cords burned annually:

Year primary heat was updated:

Auxiliary Heat Type (if applicable): —Please choose an option—WoodstoveWood insertPellet stove

# of cords burned annually (if applicable):

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

Type:
—Please choose an option—CopperAluminumKnob and tubeOther

If other, provide details:

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
Details: PedestalFloor SuckerSubmersibleWater Powered
Aux. power: NoneBatteryGenerator
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 $:

Does the dwelling have any of the following?

Pool:YesNo

If yes: In groundAbove ground

Hot tub:YesNo

Trampoline: YesNo

Earthquake coverage required: YesNo

Number of cannabis plants grown on premises:

Monitored Burglary Alarm YesNo

Interior sprinkler system in your unit: YesNo

Home Base Business: YesNo

Name of business:

Type of business:

Clients visit home: YesNo

Do you have a current CGL: YesNo

Website:

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

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I understand and accept the risks of communicating by email.* Yes