MOBILE HOME INSURANCE APPLICATION FORM

Please fill out the mobile home insurance application below to the best of your ability.  If you have any issues, please don’t hesitate to call us at 1-250-365-3368.  We will follow up after we successfully receive your submission.

    Client Details:

    Name*:

    Date of birth*:

    Phone*:

    Email:

    Location Address*:

    Mailing Address (if different):

    Name of Mobile Home Park (if applicable)

    Additional Named Insured:

    Union Member? YesNo

    If yes, provide details:

    Additional Members:

    #2 Name:

    Date of birth:

    Phone:

    Email:

    #3 Name:

    Date of birth:

    Phone:

    Email:

    #4 Name:

    Date of birth:

    Phone:

    Email:

    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, 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:

    Insured Since:

    Insured w/ Broker Since:

    Property Insured Since:

    Occupied Since:

    Mortgage / Credit Consent

    Mortgage: YesNo

    Credit Consent: YesNo

    If yes: VerbalWritten

    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

    Length:

    Width:

    Purchase Price:

    Content Value:

    # of smoke detectors:

    Garage:

    Type:

    # of cars:

    Any decks or porches:YesNo

    If yes, Size:

    Any additions:YesNo

    If yes, Size:

    Is it fully skirted:YesNo

    Roof:

    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:

    If Central Furnace, type:

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

    Year primary heat was updated:

    Auxiliary Heat Type (if applicable):

    # 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:

    Tank information:

    Year manufactured:

    Electrical

    Type:

    If other, provide details:

    BreakersFuses

    Amps:

    Other:

    Year of any updates to electrical:

    Plumbing

    Type:

    Describe Other if selected

    Hot Water:

    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 $:

    Home Base Business: YesNo

    Name of business:

    Type of business:

    Clients visit home: YesNo

    Do you have a current CGL: YesNo

    Website:

    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