Home Insurance Application Submission of this information does not represent a binding of any insurance contract or agreement. Additional information may be required in order to get an accurate quote of insurance. Name First Last PhoneEmail Date of BirthMM-DD-YYYYHave You Ever Had A Cancalletion for Non-payment, claims or cancelled for Any Other reason? Yes No If Cancelled Please Describe, When Cancelled and for what:Are You A First Time Home Buyer? Yes No Have You Ever Had Any Claims? Yes No If You Have Had Claims: Please Describe, How Many Claims, The Date, What Occured and How Much The Claim Was For:Is this A Smoke-Free House Hold? Yes No Absolutely no one living in the household smokesHow Many Mortgages Do You or Will You Have On The Property?How Many Years Have You Had Continuous House Insurance?How Long Have You Had House Insurance On The Current Property?Date Property First Purchased or If New Purchase – The Closing DateMM-DD-YYYYProperty DetailsAddress for House Insurance Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code This Application is for primary house insurance, where you live there as the homeowner.Please Confirm If you Live in The House: Yes I Live in the House No I Live Elsewhere Is the House Vacant or Will it Become Vcant? Yes, it will be vacant or is vacant Not vacant Since What Date is it Vacant or Date it will it Become Vacant?Is Any Part Of The House Rented Out? Yes No Is The Rented Portion of the House its Own Unit? Yes No Unit: a portion of the house that has its own separate entrance, separate kitchen and bathroom and is not shared with other occupants of the house, other than the people living within that specific unitWhat Year Was The House Built:Type of Electrical Panel: Breakers Fuses Other Electrical Panel Amperage 100 200 More than 200 Less than 100 Type of Wiring: Copper Aluminum Copper / Aluminum Mix Knob & Tube Mixed / Other Other – Please DescribeType of Heating Central Furnace Radiator / Boiler Electric Baseboard Other Type of Heating – Other – Please DescribeHeating Fuel Natural Gas Propane Oil Other Heating Fuel Other: Please Describe:Any Fireplaces or Wood Stoves? Yes No Type of Plumbing Supply Lines: Copper Pex Kitec Galvanized Steel Other / Mix Other / Mix Plumbing Lines – Please DescribeType Of Roof: Ashphalt Shingle Metal – Tile / Standing Seam Other Other Type of Roof – Please DescribeHow Man Years Old is The Roof?Basically how many years ago was the roof replaced.Is There A Basment Yes – Finished 100% Yes – Finished 50% Yes – Finished Less than 50% No Basement Does The Property Have A Backwater Valve Installed? Yes No Does The Property Have A Sump Pump Pit? Yes No Does The Sump Pump Have An Alarm with Battery Backup? Yes No Is There A Garage Yes – Attached Yes – Detached No Consent* I agree to the Privacy Policy and acknowledge the Disclosure Statement.
