Name of Applicant (required) Mailing Address: 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 Structure Type: DetachedSemi-DetachedTownhouseCondoRowhouseDuplexTriplexMulti-PlexOther Occupancy: Number of Residents 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 MonoxideHeatBuglary How 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 Outbuilding(s) Please complete (describing construction, occupancy, square footage and value) any outbuildings not attached to the main building. Notes: If you would like a quote for multiple location, please complete another application and note it is “Location 2” in the Notes Section
