VACANT DWELLING APPLICATION

Consent : Personal Information Privacy and Electronic Document Act (PIPEDA) Consent*
I agree to the privacy policy. Personal Information Privacy and Electronic Document Act (PIPEDA) Consent This form collects personal contact information so that we may correspond with you and provide the results of your quotation. It also collects underwriting information about your automobile, personal property, driving record and claims history. This information is required by the insurance company to provide a rate for insurance coverage. It may be submitted to an insurance company for the single purpose of obtaining a quote. I give consent for the information provided in this form to be used by Insureit Group Inc. And its representatives.This form collects personal contact information so that we may correspond with you and provide the results of your quotation. It also collects underwriting information about your automobile, personal property, driving record and claims history. This information is required by the insurance company to provide a rate for insurance coverage. It may be submitted to an insurance company for the single purpose of obtaining a quote. I give consent for the information provided in this form to be used by Insureit Group Inc. And its representatives.

How Many Registered Owners*
- One Owner
- Two Owners
Name Owner #1*
First Last
Name Owner 2
First Middle Last
Address*
Street Address City Province Postal Code
Owner #1 Date of Birth*
Owner #2 Date of Birth
Phone*
Email*
Occupation Owner #1*
Occupation Owner#2

Any Mortgagee?*
Mortgagee Name
Mortgagee address with postal code
Street Address City State / Province / Region ZIP / Postal Code
Number of liens/encumbrances/mortgages:*

Previous Insurance Company Name
Previous Insurance Claims?*
If Claim's is Yes Explain

When did you first occupied the house*
Hydrant Protected?*
Meters To Hydrant*
Kilometers to fire hall*

Year Built*
Total Square Footage Basement*
Total Square Footage (Exclude Basement)*
Architecture style*
Construction*
Number of Full Bathrooms*
Number of 2 Piece Bathrooms
Basement Finished?*
Walkout Basement*
Monitored Alarm Protection?*
# of Garages*
Swimming Pool?*
Porch? Size in sqft
Deck Size in sqft
Additional Areas (Indoor Basketball Court, Solarium……
Occupied Since?*
Any Additional Features?*

Year Heating Renovated*
Primary Heating*
If Primary Heating other Describe

Year Electrical Renovated*
Electrical*
Electrical System*
Electrical System Details*
Electrical System Details Other Describe

Year Roofing updated*
Roof Material*
Roof Material Other Describe

Year Plumbing Updated*
Type of Plumbing:*
if Other/Combined:

Building Details*
If Building Details Other
Does property have operational smoke detectors?*
Who is responsible for the care and maintenance of the property?
If maintenance of the property Other Describe
Is there a swimming pool on the premises?*
Caretakers Name and Phone Number:*

Has this risk been declined, refused or cancelled by another insurer?*
If Yes Reason:*
Previous insurer? If there is None ( Enter None )*
Five (5) Year Claim/Loss history (date; paid/estimated amount; cause; open/closed)?*

Is the property viewable from the road?*
Is the property on a paved road?*
Current Status:*
If Is other (describe):
Have measures been taken to maintain the property/grounds & prevent the dwelling from looking unoccupied?*
Is the property being maintained in a usable and saleable condition at all times (i.e. no boarded up windows)?*
Is the property checked every 72 hours by a competent person?*
Name of person checking dwelling every 72 hours:*
Are there any sewer backup losses, insured or otherwise, at this location in the past 5 years?*
Are there any other types of losses, insured or otherwise, at this location in the past 5 years?*
If yes, please provide details:

Date dwelling became/will become vacant (vacant max 21 months to date):*
MM slash DD slash YYYY
Requested Effective Date:*
MM slash DD slash YYYY
Requested Expiry Date (min 3 month term):*
MM slash DD slash YYYY
Will the building be slated for demolition?*
Will there be any renovations?
If there will be renovations, what is the budget?$
If there will be renovations, will there be any structural renovations?*
If there be any structural renovations

LIMITS REQUIRED: Building: $*
Detached Structures: $
LIMITS REQUIRED: Major Appliances: $*
LIMITS REQUIRED: Rental Income: $*
Consent*
I agree
PLEASE READ BEFORE SIGNING: A claim will become invalid and the Insured’s right of recovery is forfeited where (a) an Applicant for this contract gives false particulars to the prejudice of the insurer or
knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or (b) the insured fails to inform material changes to these facts during the term of the contrac t; (c)
the insured contravenes a term of the contract or commits a fraud; or (d) the insured willfully makes a false statement in respect of a claim.
The Applicants have reviewed all parts and attachments of this application and acknowledge that all information is true and correct and understand that this application for insurance is based on the truth and
completeness of this information.
The personal information provided in this document and in the future including, but not limited to, credit information and claims history may be collected, used and disclosed by the insured’s representative or
insurance company, subject to local legislation, for the purpose of communicating with the insured or their representative, assessing the application for insurance and underwriting any such policies, evaluating
claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal informa tion is contained in this document have authorized that I agree to the above on their
behalf.
NOTE: Insurance is not in effect until BROKER has issued a binder or policy documents.
Name*
First Middle Last

VACANT DWELLING APPLICATION ONLINE

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