TENANTS INSURANCE APPLICATION FORM

Please fill out the tenants 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):

    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

    New Purchase Closing Date:

    Move in Date:

    Credit Consent

    Credit Consent: YesNo

    If yes: VerbalWritten

    Personal Property Limit

    Contents Limit for Personal Property ($):

    House Details

    Style of home:

    Type of home: DetachedSemi-detached

    Year Built:

    Sq. ft. Total Living Area:

    Type of exterior siding:

    Number of kitchens:

    Number of bathrooms:

    Number of smoke detectors:

    Garage:

    Type:

    Number of cars:

    Is there a basement or crawlspace?

    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:

    Dwelling Construction

    Dwelling Construction Type: Wood FrameLogSteelPanabodeConcrete

    Roof

    Roof type: Asphalt ShinglesClay TileAluminiumSteelWood ShakeTar and GravelTorch on Membrane

    Year of Roof Update:

    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

    Electrical

    Type:

    If other, provide details:

    BreakersFuses

    Amps:

    Other:

    Year of any updates to electrical:

    Additional Questions

    Is the dwelling under construction / renovations? YesNo

    If yes, provide additional information:

    Earthquake coverage required: YesNo

    Number of fire extinguishers:

    Monitored Burglary Alarm YesNo

    Fire Alarm: YesNo

    Sprinkler system: YesNo

    Number of families living in the home:

    Any: RoommatesBordersStudents

    If yes, provide additional information:

    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

    Number of cannabis plants grown on premises:

    Additional security options: Block WatchWalled CommunityDead Bolt Locks24Hr Video SystemSecured EntranceSecurity GuardIntercom