Vacant House Insurance Application Submission of this information does not represent a binding of any insurance contract or agreement. Additional information may be required in order to get an accurate quote of insurance. Name First Last PhoneEmail Date of BirthMM-DD-YYYYHave You Ever Had A Cancalletion for Non-payment, claims or cancelled for Any Other reason? Yes No If Cancelled Please Describe, When Cancelled and for what:Have You Ever Had Any Claims or Has the location had any losses, insured or otherwise in the past 5 years? Yes No If You Have Had Claims: Please Describe, How Many Claims, The Date, What Occured and How Much The Claim Was For:How Many Mortgages Do You or Will You Have On The Property?How Many Years Have You Had Continuous House Insurance?Property DetailsAddress for House Insurance Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code This Application is for primary house insurance, where you live there as the homeowner.What Year Was The House Built:What is the Status of the Property? Check All that Apply To Be Sold Will be Owner Occupied Owner Temporarily relocated Will be rented out dwelling in estate property under financial distress renovations being peformed Other If there will be renovations, what is the budget?If there will be renovations, will there be any structural renovations? Yes No Describe the type of renovations, who will be doing the renovations and all the type of work to be completed:Other – please describeIs the property viewable from the road? Yes No Is the property on a paved road? Yes No Have measures been taken to maintain the property/grounds & prevent the dwelling from looking unoccipied? Yes No Is the Property being maintained in a usable and saleable conditional at all times (i.e. no boarded up windows)? Yes No Is the property checked every 72 hours by a competent person? Yes No Who Checks on the property every 72 hours?Type of Electrical Panel: Breakers Fuses Other Electrical Panel Amperage 100 200 More than 200 Less than 100 Type of Wiring: Copper Aluminum Copper / Aluminum Mix Knob & Tube Mixed / Other Other – Please DescribeType of Heating Central Furnace Radiator / Boiler Electric Baseboard Other Type of Heating – Other – Please DescribeHeating Fuel Natural Gas Propane Oil Other Heating Fuel Other: Please Describe:Any Fireplaces or Wood Stoves? Yes No Type of Plumbing Supply Lines: Copper Pex Kitec Galvanized Steel Other / Mix Other / Mix Plumbing Lines – Please DescribeType Of Roof: Ashphalt Shingle Metal – Tile / Standing Seam Other Other Type of Roof – Please DescribeHow Man Years Old is The Roof?Basically how many years ago was the roof replaced.Is There A Basment Yes – Finished 100% Yes – Finished 50% Yes – Finished Less than 50% No Basement Does The Property Have A Backwater Valve Installed? Yes No Does The Property Have A Sump Pump Pit? Yes No Does The Sump Pump Have An Alarm with Battery Backup? Yes No Is There A Garage Yes – Attached Yes – Detached No Date dwelling became/will become vacant:What would be the requested expiry date (the date you wish the policy to end)Will the building be slated for demolition? Yes No Consent* I agree to the Privacy Policy and acknowledge the Disclosure Statement.Untitled
