Name of Applicant (required)

Mailing Address:

City (required):

Phone Number:

Email (required)

Referred by:

Do you currently have insurance?

yesno
Is renewal being offered?
yesno
If not, why?

Date Required for Coverage?

Property Information

Property Address

Property City

Structure Type:
DetachedSemi-DetachedTownhouseCondoRowhouseDuplexTriplexMulti-PlexOther

Occupancy:

Number of Students

Annual Rental Income:
Type of Area
ResidentialCommercial
Is the property occupied all 12 months?
yesno

Construction:

Number of Stories:
Year Built:
Square Footage of Property:
Wall type:FrameBVBrick/StoneSidingModularFire Resistant
Roof Type:ShinglesMetalFlat
Number of Kitchens:
Number of Bathrooms:
Updates to Property:FullPartial
Year of Updates:

Utilities - Heat:

Primary Heat:Gas FurnaceElectricOilWood
Auxiliary Heat:ElectricWood
Updates to Heating:FullPartial
Year of Updates:

Wood Heat Used:Wood stoveWood FurnaceFireplace Insert Combination Furnace
ULC Approved?YesNo

Oil Heat Used?InsideOutsideAbove GroundIn Ground
Age of Tank:
Date of Last Inspection:

Utilities - Electrical

Electrical Panel:BreakersFuses
Electrical Wiring:CopperAluminum
Electrical Updates?FullPartial
Year of Updates:

Utilities - Plumbing

Plumbing Pipes:CopperPVCOther
Plumbing Updates:FullPartial
Year of Plumbing Update(s):
Sump Pump?YesNo
Sump Pump Age:

Protection:

Fire Protection:Hydrant within 300 metersFirestation within 8 km
Alarms:SmokeCarbon MonoxideHeatBuglaryHow are Alarms monitored?LocalMonitoredCentral
ULC Approved?
YesNo

Housekeeping

Is the property kept well?ExcellentGoodFairPoor

Overall Condition

Overall Physical Condition of the Property:ExcellentGoodFairPoor

Supervision:

Responsible individual/property manager providing personal visits to premises every 30 days? YesNo