(Fields marked * are required.)

Property Insurance Application

Section 1: APPLICANT INFORMATION




















Section 2: BUSINESS OPERATIONS


Section 3: LOSS HISTORY



Yes No
Yes No
Yes No

Section 4: PROPERTY LOCATIONS

The following form allows you to enter relevant information on the property that is to be part of your insurance coverage. To add a second property, click the "Add another location" button at the end of the form.



Building Description

HCB Fire Res Tilt Up Frame Other
Wood Deck Wood Joist Steel Deck Concrete
T&G Metal Duroid Concrete
Gas Oil Electric Boiler Other
Breakers Fuses Conduit
Concrete Wood Other
Yes No

Public Protection: Hydrant within  
  metres, Firehall within  
  metres


Yes No
Yes No
Yes No
Yes No
Yes No
Local Monitored

Excellent Good Average Fair Poor

Yes No

Section 5: COVERAGES REQUIRED (Property & BI — Complete by Broker)

Fill in all applicable fields.

CoverageCo. Ins.NP/ARRC/ACVDedLimitRatePremium
Building
Equipment
Stock
EDP
Transit
Gross Earn.
Extra Expense
Rental Value
Gross Rents
Profits
Accounts Rec.
Valuable Papers
Signs
Contractors Eq.
Misc. Prop Floater
Other

Referral

NOTICE TO APPLICANT

Consumer and previous insurer reports containing personal, credit, factual or investigative information about the applicant may be sought in connection with this Applicant for Insurance or any renewal, extension or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of Insurance. The policy may be deemed to be void and claims may be denied where:
  1. An Applicant for a contract:
    1. Gives false or erroneous information to the prejudice of the insurer, or
    2. Knowingly misrepresents or fails to disclose in the Application any fact required to be stated therein; or
  2. The Insured contravenes a term of the Contract or commits a fraud; or
  3. The Insured willfully makes a false statement in respect of a claim under the contract

YOU CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENTS.

YOU ARE IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE AGREEMENT.

I accept the terms *: