HOME INSURANCE APPLICATION FORM

Preferred Location (required)

Castlegar OfficeSlocan Park Office

Condition Removal Date YYYY-MM-DD (if new purchase)

Effective Date Insurance is Required YYYY-MM-DD (required)

How did you hear about us?

Owner Information

First Name (required)

Last Name (required)

Phone (required)

Your Email (required)

Birthdate YYYY-MM-DD (required)

On Title (required)
YesNo

Secondary Applicant Information

First Name

Last Name

Birthdate YYYY-MM-DD

On Title
YesNo

Current Insurance Company (Home/Tenants/Condo)

Current Insurance Policy #

Current Insurance Policy Expiry Date YYYY-MM-DD

Mortgagee Institution

Mortgagee Address

Previous Address in Past 3 Years

Have you had any claims in the past 5 years (list details)

Have you ever been cancelled, refused, or denied insurance?

YesNo

Years Continuously insured (no gaps)

Years Claims Free

If a new primary residence, will you occupy within 30 days?

YesNo

How long have your owned or occupied this property?

Occupancy of this location (required)

PrimaryRentalSeasonalVacantNew Build

Is there an alarm system? (required)

No AlarmLocal Alarm24 hr Central Monitored AlarmFor FireFor Burglary

Fire Hydrant within 300 meters? (required)
YesNo

Fire Hall within 8 km? (required)
YesNo

Detached Outbuildings(include type, size, value, siding, roofing, year built, quality):

1. 2. 3.

Will there be any roommates or boarders? (required)
YesNo

Will there be any business on premises? (required)
YesNo

Are there any suites in the home? (required)
YesNo

Will there be any home sharing rentals? (required)
YesNo

Will there be any marijuana grown on premises? (required)
YesNo

Would you like to include Earthquake? (required)
YesNo

Would you like to say yes to credit score discount? (required)
YesNo

Would you like to pay in full or monthly? (required)
FullMonthly

Any extensions of liability/scheduled items to add (bikes/jewellery/business property) (required)

YesNo

Dwelling Information

Address (required)

Year Built (required)

Main Floor Living Area (required)

Architecture Style (required)

Bungalow1½ storey2 storeyBi-levelTri-levelDuplexMulti FamilyTownhouseLogRancherOther

Construction Type (required)

Frame, WoodLogConcreteMasonry, BrickTimber, post and beamVeneer, brick or stoneOther

Construction Quality (required)

BasicModestAverageAbove AverageExpensiveCustom

Physical Shape (required)

AngularSquareRectangleOther

Primary Exterior Siding (required)

VinylWoodStuccoBrickVeneerSolid StoneCement BoardOther

Primary Roof (required)

Asphalt ShinglesAluminumComposition, Built upFiberglass ShinglesMetal, corrugatedSteelTar and GravelOther

Bathrooms

Full (required)

Half

Description of Locale (required)

UrbanSuburbanCity, SmallRemoteRuralWaterfrontOther

Has the home been completely gutted in the last 40 years?

YesNo

Historic Registry

YesNo

Garage

NoneAttachedDetachedBuilt In1 Car2 Car

Square Footage

Year Built

Carport

NoneAttachedDetachedBuilt In1 Car2 Car

Square Footage

Year Built

Porch

NoneCoveredEnclosedOpenScreened

Square Footage

Year Built

Deck

NoneCovered (roof)Specialty WoodSynthetic LumberWood

Square Footage

Year Built

Additional Areas

½ storeyAtticBasement, finished, below gradeBasement, finished, walk outBasement, unfinished, below gradeBasement, unfinished, walk outBonus roomBreezewayCrawl spaceGreenhousePatio, coveredPatio, elevatedPergolaSolariumOther

Other

Hot TubSwimming Pool, ingroundSwimming Pool, above ground

Electrical Upgrades

Year
Copper/ Knob and Tube
Amp Service

Plumbing Upgrades

Year
Plumbing Material
Does your house have Poly-B plumbing?
YesNo

Any Galvanized/ Cast Iron

Roofing Upgrades

Year
Roofing Material

Heating Upgrades

Year
Primary Heat Source
Aux. Heat Source

Hot Water Tank Upgrades

Year
Gas/ Electric
Tankless/ Standard

Municipal Sewer/ Septic

Sewer Back Up Valve

If using wood heat, how many chords are burned /year

If using wood heat, is your unit CSA approved and WETT inspected (copy of WETT required)

*CURRENT COLOURED PHOTOS OF FRONT, BACK OF HOME AND OUTBUILDINGS REQUIRED FOR QUOTING
*WETT INSPECTION & COMPLETED WOODHEAT QUESTIONNAIRE FOR ALL WOOD BURNING UNITS REQUIRED
*ALL SUITES OR RENTING OF SUITES MUST BE DECLARED PRIOR TO INSURANCE BEING BOUND

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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