Habitational Insurance Application
	RISK IDENTIFICATION
	Agent/Broker:
	Policy Number:
	Name of Applicant:
	Mailing Address:
	Postal Code:
	Telephone Number:
	Period of Insurance (From):
	Period of Insurance (To):
	Risk Location (if different from applicant's address):
	Loss Payee(s), if any:
	APPLICANT'S INFORMATION
	Date of Birth of Applicant (YY/MM/DD):
	Date of Birth of Spouse (YY/MM/DD):
	Occupation:
	Name of Employer:
	Years Employed:
	Previous Losses (past 5 years):
	Claim Free Period (in years):
	Previous Insurer:
	Policy Number:
	Has any Insurer cancelled or refused insurance during the past 5 years:	Yes No If yes, describe:
	BUILDING INFORMATION
	Age/Year Built:
	Number of Storeys:
	Main Floor Area:	Square Feet
	Total Area:	Square Feet
	Renovation Update, if any:	Electrical Heating Plumbing Roofing When:
	Structure:	Detached Semi-detached Town-house Apartment Other:
	Occupancy:	Primary Secondary Seasonal Rented Other:
	Construction:	Frame Brick Veneer Masonry Fire Resistive Other:
	Heating:	Furnace Central Natural Gas Electric Other:
	Security System:	Fire Alarm Burglar Alarm Local Monitored Smoke Detector
	Additional Information:	Number of Families:   Number of Rooms Rented to Others:   Number of Units (for apartment):   Business Operation Daycare Saddle/Draft Animals
	COVERAGES, FORMS AND LIMITS
	Policy Type:	Homeowner Secondary Seasonal Tenants Other:
	Policy Form:	Standard Named Perils Broad Prestige Comprehensive Other:
	Dwelling Building:	$
	Detached Structures:	$
	Personal Property:	$
	Additional Living Expenses:	$
	Personal Liability:	$
	Vol. Medical Payments:	$
	Vol. Property Damage:	$
	Estimated Base Premium:	$
	ADDITIONAL COVERAGE LIMIT RATE PREMIUM Earthquake : Deducible % $ @ $ Sewer Backup $ @ $ Other: $ @ $ Total Base Premium and Additional Coverages Premium: $
	HOME EVALUATION
	Roof Material:	Clay and Slate Tile Metal Tile Wood Shingles Wood Shakes Asphalt Shingle Corrugated Steel Rubber Concrete Tile Mineral Fiber Shakes Tar & Gravel
	Bathroom:	Number of Full Bathrooms:   Number of Half Bathrooms:
	Finished Basement:	Recreation Room Area:     Square Feet Living Quarters Area:     Square Feet
	Fireplace(s):	Type & Number:   Number of Inside Chimney:   Number of Outside Chimney:
Garage(s):	Attached Detached Masonry Frame 1 Car 2 Car 3 Car
Carport(s):	With Storage Without Storage 1 Car 2 Car 3 Car
Swimming Pool:	Material: Reinforced Concrete Fiberglass Surface Area:     Square Feet
Security System(s):	Fire Alarm Burglar Alarm Local Monitored Block Watch 24 Hours Security Guard
Electrical:	100 AMPS Breakers Fuses Other:
REMARKS
Glass Service Contract: Premium $