Tenant Insurance Application

Please complete and submit this application form to receive your tenant insurance quote. Fill in all fields, entering N/A if not applicable.

Applicant Name(s)

Date of Birth of Insured(s)

Phone

Occupation

Insured Property Address

City

Postal / Zip code

Region/State/Province

Effective Date (MM/DD/YYYY)

Year Built

Hot water tank in unit?

Number of Stories

Number of Units

If yes, how old is the hot water tank?

Sprinklers (In Suite)

Building Construction

Frame (Wood Apartment)

Fire Resistive

High-rise (Concrete)

IF OLDER THAN 25 YEARS, PROVIDE YEAR OF UPDATES & TYPE:

Roof

Plumbing (Copper?)

Electrical (Curcuit Breakers — Fuses — Knob & Tube?)

Heating (Hot Water, N/G Furnace, Electrical Baseboard?)

Any unrelated roommate(s)/boarder(s)?

Operate Business in Premises?

Replacement Cost of Contents (minimum $40,000)

Earthquake

Yes

Sewer Backup/Water Escape

Yes

Any items to be Scheduled? (Jewellery, Bicycles etc.)

Since when you have been living at the risk location?

Do you currently have a policy for this location? (Name of the Insurance Company, Policy Number and Expiry Date)

CONTINUOUSLY having a residential insurance policy for any location(s) since

Do you have any LOSSES or CLAIMS in the past 10 years at any location(s)? If yes, please list detail.

Have you ever had a policy canceled for non-payment in the past 3 years?

CONSENT FOR "SOFT" CREDIT CHECK (Additional Discount on Rating)

Yes

Thanks, we'll be in contact soon.