| Contact Information |
| 1st Applicant - Last Name |
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| 1st Applicant - First Name |
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| 1st Applicant - Occupation |
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| 2nd Applicant - Last Name |
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| 2nd Applicant - First Name |
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| 2nd Applicant - Occupation |
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| Address |
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| City |
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| Province |
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| Postal Code |
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* Preferred method of contacting you (at least one) |
| E-mail |
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| Work Phone |
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| Home Phone |
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Residence Type & Features |
| Residence type |
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| Owner Occupied? |
Yes No |
| Business operations conducted on premises? |
Yes
No |
| Year built: |
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| Number of stories: |
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| Is the home custom built? |
Yes No |
| Sq. ft. on main level? |
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| Sq. ft. for finished basement? |
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| Sq. ft. for wood decks? |
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| Sq. ft. for verandahs/porches? |
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Number of full bathrooms?
(3 fixtures) |
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Number of half bathrooms?
(2 fixtures) |
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| Fireplace? |
Yes No |
| If fireplace, chimney type? |
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| Central air conditioning? |
Yes No |
| Aboveground swimming pool? |
Yes No |
| If Yes, please indicate value: |
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| Garage? Choose type. |
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| Sq. ft. of sunroom, if any? |
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Built-ins (please check all that apply): |
| Air Conditioner (wall unit) |
Microwave |
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Air Exchanger |
Oven/Range |
| Central Vacuum System |
Refrigerator |
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Countertop Range |
Sauna |
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Dishwasher |
Security & Fire Alarm |
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Dryer (built-in) |
Skylight |
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Electronic Air Filter |
Smoke Alarm (electrically wired) |
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Garage Door Opener |
Video-door-answering System |
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Heat Exchanger |
Washer (built-in) |
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Hot Tub (not Jetted Tub) |
Water Purification System |
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Intercom System |
Water Softener |
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Jetted Hot Tub |
Wet Bar |
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Jetted Tub * |
Whole-house Fan |
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Interior Sprinkler System |
Wood-burning Stove |
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* addition to standard tub |
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Scheduled Items |
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| Bikes: |
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| Satellite Dish: |
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| Other: |
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Fire Protection |
| Within 300 metres of a hydrant? |
Yes No |
| Within 8 km of a responding fire hall? |
Yes
No |
| Unprotected |
Yes No |
| Type of construction |
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| Wood frame |
Yes No |
| Masonry/Fire resistive |
Yes No |
| % of exterior wall that is brick/stone |
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Heating |
| Primary heat is |
Gas |
Oil |
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Electric |
Combination |
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If built over 20 years, please advise the following: |
Electrical
Ex: Circuit breakers, Fuses |
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| Heating |
Information requested above. |
Plumbing
Ex: PCV, Copper, Galvanized |
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Roof
Ex: Asphalt, Other |
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Current Insurance |
| Current insurance company |
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If first-time insured, type NONE |
| Current insurance broker |
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If first-time insured, type NONE |
| Policy # |
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| Policy expiry date |
dd/mm/yy |
| Claims history |
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| (any losses over past 5 years) |
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Discounts |
| Claims free 3 yrs |
Yes No |
| Mature citizen |
Yes No |
| Non smoker |
Yes No |
| Mortgage-free |
Yes No |
| Alarm system |
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| Comments: |
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Form type |
| Broad or Comprehensive |
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