|
| Name:
|
|
| First
name: |
|
| Spouse's
name, if applicable: |
|
| Address: |
|
| City: |
|
| Postal
code: |
|
| Telephones: |
|
| Email: |
|
| Date
of birth: |
|
| Date
of birth (spouse): |
|
| Occupation: |
|
| Occupation
(spouse): |
|
| Employer's
name : |
|
| Employer's
name (spouse): |
|
Present
insurer:
(name of the insurance company,
policy number and expiry date) |
|
Cancellation
or non-renewal of an insurance policy in
the past:
(provide the details in Specials
considerations, if applicable) |
|
| Smokers: |
|
| Criminal
antecedants: |
|
| Alarm
system connected to central station: |
|
| Distance
to a fire hydrant: |
|
|
Proximity to a fire department: |
|
| Owner
or tenant: |
|
Dog,
cat or other animals:
(provide details) |
|
| Dug-in
or above-ground pool: |
|
| Roof
redone in the past 20 years: |
|
| Oil
tank replaced in the past 20 years: |
|
| Do
you take in persons or provide care: |
|
| Business
or commercial office: |
|
| Claims
or incidents in the past 6 years: (provide
dates, circumstances and amounts) |
|
Describe
building:
(bungalow, cottage, duplex,
frame with brick siding, garage, etc.) |
|
| Year
of construction: |
|
Type
of heating:
|
|
Auxiliary
heating:
(slow-burning stove, etc.) |
Montant
courant de l'hypothèque:
|
| Cancellation
or non-renewal in the past: |
|
Coverages
requested:
(minimum deductible $300
)
|
|
| Amounts
requested: |
|
| Deductible
requested: |
|
Name
and address of mortgagee:
(include the postal code)
|
|
| Current
amount of the mortgage: |
|
| Special
considerations: |
|
| Digital
photos: |
|
|
|
|
