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Building Information

Coverages

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Address

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Applicant Information

Do you currently carry homeowners, tenants or condo insurance?

Do you currently carry homeowners, tenants or condo insurance? Please specify whether or not you have prior insurance.

Yes

Insurance companies use prior insurance as one of the factors when they are considering your rate. If you do not have prior insurance, the quote will generally be higher until you establish your insurance history.

Currently Insured Question

Year you have had continuous property insurance since Please specify the date you have had continuous property insurance since

Continuous insurance suggests reliability. This information is used to provide an accurate quote.

What is the name of your current property insurer? Please be advised if you are currently insured with Intact Insurance Company for your rented rwelling we will need to discuss further items prior to binding this policy. Please contact us at 1-800-679-2640 ext 270

The name and policy number of your current/prior insurance company is used to verify your claims record. Your insurance company name and policy number is found on your policy documents.

Date of birth? Please select a valid date Please specify your date of Birth.

Insurance rates will vary depending on the policy holder's age. Some insurance companies also offer age discounts.

First Name Please complete this field.

Last Name Please complete this field.

Is there a co-applicant?

Is there a co-applicant? Please specify whether or not there is a Co-Applicant.

Yes

A co-applicant is anybody who also has a financial interest in the property and/or contents. For example; someone named on the mortgage, deed, rental agreement, or lease. For this reason, co-applicants should always be named on the insurance policy.

CoApplicant

Co-Applicant First Name Please specify the Co-Applicant first name.

Co-Applicant Last Name Please specify the Co-Applicant last name.

Co-Applicant Birthdate Please select a valid date Please specify the Co-Applicant's date of birth.

How many property claims have you had in the past five years?

How many property claims have you had in the past five years? Unfortunatley since you have more than 4 claims, you must contact us for a quote at 1-800-679-2640. Please specify whether or not you have had a claim in the past five years.

A claim can be defined as; when a policy holder files for reimbursement from their insurance company for damaged or destroyed property and/or lost personal belongings. The number and date of the claim(s) may affect the estimated premium. The date of claim(s) will be determined in upcoming questions.

Claims

Type of Claim

Date of Claim Please select a valid date

Amount of Claim

Type of Claim

Date of Claim Please select a valid date

Amount of Claim

Type of Claim

Date of Claim Please select a valid date

Amount of Claim

Type of Claim

Date of Claim Please select a valid date

Amount of Claim

How many times has an insurer cancelled your policy in the past 3 years?

How many times has an insurer cancelled your policy in the past 3 years? Unfortunatley since you have more than 2 cancellations, you must contact us for a quote at 1-800-679-2640. Please specify whether or not you have been cancelled for non-payment in the past 3 years.

If your policy has been cancelled for non-payment this will affect the policy type and premium that the insurance company is willing to offer you.

Cancellation

If your policy has been cancelled for non-payment this will affect the policy type and premium that the insurance company is willing to offer you.

Type of Cancellation

Date of Cancellation Please select a valid date

Type of Cancellation

Date of Cancellation Please select a valid date

Do you occupy the dwelling?

Do you occupy the dwelling? Unfortunately due to our underwriting guidelines we are unable to provide a quotation for a dwelling that is not occupied by the owner. Please specify whether or not you occupy the dwelling.

Yes

Vacant dwellings (defined as; circumstances where all occupants have moved out of the dwelling with no intention of returning and no new occupants are expected) usually require special provisions to retain proper coverage.

Occupancy

Number of families occupying each unit

Number of families occupying each unit Unfortunately due to our underwriting guidelines we are unable to provide a quotation for a dwelling that has more than 1 family Please the number of families that occupy the dwelling.

Enter the number of unrelated occupants living at the residence (in this scenario, common-law partners ARE considered family). Some insurance companies consider multiple-family occupancy to be a liability and may charge higher premiums.

Number of Families

Are all residents of the dwelling non-smokers?

Yes

Dwellings with residents who smoke have been proven to higher incidences of fires than that of non-smoking residents. Insurance companies will take this information into consideration when calculating premiums.

Smoking

Are you a CAA member?

Yes No

Please select an option

Initial CAA membership date

Please complete this field. Please Enter a valid date in the format (MM/DD/YYYY)

CAA membership number

Please complete this field.

First Dog Breed Please select a dog breed. Unfortunately if your dog is any of those that appear in this list we cannot insure you due to our underwriting guidelines.

Owning a vicious pet or keeping one on the property severely increases the risk exposure of the property. Many insurance companies do not insure a risk with a vicious pet on the premises.

Second Dog Breed Please select a dog breed. Unfortunately if your dog is any of those that appear in this list we cannot insure you due to our underwriting guidelines.

Owning a vicious pet or keeping one on the property severely increases the risk exposure of the property. Many insurance companies do not insure a risk with a vicious pet on the premises.

Third Dog Breed Please select a dog breed. Unfortunately if your dog is any of those that appear in this list we cannot insure you due to our underwriting guidelines.

Owning a vicious pet or keeping one on the property severely increases the risk exposure of the property. Many insurance companies do not insure a risk with a vicious pet on the premises.

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RS MEANS - Dwelling Type

Single Family Home (Detached House)

This category of residence is a free-standing, separate building with or without an attached garage. It has at least four complete walls.

Multi-Family Home

This category of residence has more than one living unit.

Included are 2 kitchens, an additional heating system, and upgraded electrical circuits.

Means CostWorks Valuator requires the total square footage of the multi-family structure and the total number of bathrooms for the entire structure in order to calculate a valuation.

Town/Row House

This category of residence has a number of attached units made up of inner units and end units. Common walls join the units. The inner units have only two exterior walls. The common walls are fireproof. The end units have three exterior walls and a common wall. Town/Row houses can be any of the building types.

Group Code(optional):

Address of Rented Dwelling

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Applicant Information

Single Family Home (Detached House)

Multi-Family Home

Town/Row House

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