VACANT DWELLING APPLICATION ONLINE Vacancy Permit Insurance Application Click Here for Pdf application VACANT DWELLING APPLICATIONStep 1 of 156%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 OwnersName Owner #1* First Last Name Owner 2 First Middle Last Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Owner #1 Date of Birth*Owner #2 Date of BirthPhone*Email* Occupation Owner #1*Occupation Owner#2Any Mortgagee?*Any Mortgagee?YesNoMortgagee NameMortgagee address with postal code Street Address City State / Province / Region ZIP / Postal Code Number of liens/encumbrances/mortgages:*Previous Insurance Company NamePrevious Insurance Claims?*Previous Insurance Claims?YesNoIf Claim's is Yes ExplainWhen did you first occupied the house*Hydrant Protected?*Hydrant Protected?YesNoMeters To Hydrant*Kilometers to fire hall*Year Built*Total Square Footage Basement*Total Square Footage (Exclude Basement)*Architecture style*Architecture styleBungalowTwo StoreyTown HouseSemi DetachedOtherConstruction*ConstructionAutoclaved Aerated ConcreteFoam Form ConcreteFraming, SteelFraming, WoodFraming, Wood with Elevated SlabLog A typeMasonry, BlockMasonry, BrickMasonry, StoneModular, Wood FramePoured ConcreteRammed EarthStickSoil CementStructural Insulated PanelStucco on FrameStucco on MasonryTimber/Post & BeamVeneer, BrickVeneer, Brick with Wood FrameVeneer, StoneNumber of Full Bathrooms*Number of 2 Piece BathroomsBasement Finished?*Basement Finished?YesNoWalkout Basement*Walkout BasementYesNoMonitored Alarm Protection?*Monitored Alarm Protection?YesNo# of Garages*# of GaragesNone1 Vehicle2 Vehicles3 VehiclesMore then 3Swimming Pool?*Swimming Pool?NoneYesPorch? Size in sqftDeck Size in sqftAdditional Areas (Indoor Basketball Court, Solarium……Occupied Since?*Any Additional Features?*Any Additional Features?NoneSaunaExtra KitchenSkylight,SprinklerOtherYear Heating Renovated*Primary Heating*Primary HeatingCentral Furnaces GasCentral Furnaces OilCentral Furnaces PropaneCentral Furnaces WoodElectricHot water / SteemSolid FuelSolid Fuel PelletSolid Fuel OilSolid Fuel CoalSpace Heater GasSpace Heater OilSpace Heater ElectricWood Burning StoveFire PlaceFire Place InsertSolarHeat PumpHeat Pump OilOtherNoneIf Primary Heating other DescribeYear Electrical Renovated*Electrical*ElectricalCircuit BreakerFusesElectrical System*Electrical System60AMP100AMP200AMPElectrical System Details*Electrical System DetailsCopperAluminumKnob & TubeOtherElectrical System Details Other DescribeYear Roofing updated*Roof Material*Roof MaterialAluminumArchitectural ShingleAsbestos Shingle ReplacementAsphalt ShingleBarrel TileCedar Shingle/ShakeCement FiberClay TileComposition RollComposition ShingleComposition, Built-upConcrete TileDibitonDimensional Asphalt ShingleEPDM MembraneFibreglass ShingleGlazed TileHail Proof ShingleLamarite ShingleMetal, CorrugatedTar and GravelWood ShakeWood ShingleSpanish TileOtherRoof Material Other DescribeYear Plumbing Updated*Type of Plumbing:*Type of Plumbing:CopperPEXGalvanized SteelPolybutyleneCast IronOther/Combined:if Other/Combined:Building Details*Building DetailsDetachedCondo/TownhouseRowhouseMobile HomeOther (Please describe):If Building Details OtherDoes property have operational smoke detectors?*Does property have operational smoke detectors?YesNoWho is responsible for the care and maintenance of the property?Who is responsible for property maintenance?InsuredNeighborProperty ManagerFriend/RelativeTenantOther(describe):If maintenance of the property Other DescribeIs there a swimming pool on the premises?*s there a swimming pool on the premises?YesNoCaretakers Name and Phone Number:*Has this risk been declined, refused or cancelled by another insurer?*Has this risk been declined, refused or cancelled by another insurer?YesNoIf 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 viewable from the road?YesNoIs the property on a paved road?*Is the property on a paved road?YesNoCurrent Status:*Current Status:to be soldwill be owner occupiedowner temporarily relocatedwill be renteddwelling in estateproperty under financial distressother (describe):If Is other (describe):Have measures been taken to maintain the property/grounds & prevent the dwelling from looking unoccupied?*Have measures been taken to maintain the property/grounds & prevent the dwelling from looking unoccupied?YesNoIs the property being maintained in a usable and saleable condition at all times (i.e. no boarded up windows)?*Is the property being maintained in a usable and saleable condition at all times (i.e. no boarded up windows)?YesNoIs the property checked every 72 hours by a competent person?*Is the property checked every 72 hours by a competent person?YesNoName 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 sewer backup losses, insured or otherwise, at this location in the past 5 years?YesNoAre there any other types of 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?YesNoIf 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 the building be slated for demolition?YesNoWill there be any renovations?Will there be any renovations?YesNoIf there will be renovations, what is the budget?$If there will be renovations, will there be any structural renovations?*If there will be renovations, will there be any structural renovations?YesNoIf there be any structural renovationsLIMITS REQUIRED: Building: $*Detached Structures: $LIMITS REQUIRED: Major Appliances: $*LIMITS REQUIRED: Rental Income: $*Consent* I agreePLEASE 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