For manual submission, download this form here.
TENANT QUESTIONNAIRE
TO BE COMPLETED AND SIGNED
BY THE INSURED
. ALL VALUES ARE SUBJECT TO REVIEW BY UNDERWRITING.
NAME OF OWNER(S)
*
:
STREET ADDRESS
*
:
CITY
*
:
POSTAL CODE
*
:
PROVINCE
*
:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Québec
Saskatchewan
Yukon
BUSINESS PHONE NUMBER:
HOME PHONE NUMBER
*
:
FAX:
EMAIL ADDRESS
*
:
IS THERE ANY BUSINESS OPERATION IN THE HOME?
Yes
No
If Yes, please explain:
HOME TYPE:
Detached
Semi-detached
Apartment
# units in building:
YEAR BUILT:
If over 25yrs, please indicate the year when the following have been updated:
Heating
Plumbing
Wiring
Roof
PRIMARY HEATING:
Gas
Oil
Woodstove
Other
If Oil, is the tank
Inside ?
Outside ?
Is the tank
Above Ground
Below Ground
Age of tank
SECONDARY HEATING:
Gas
Oil
Woodstove
Other
If Oil, is the tank
Inside ?
Outside ?
Is the tank
Above Ground
Below Ground
Age of tank
AMP SERVICE:
NUMBER OF STORIES:
SQUARE FOOTAGE OF ENTIRE HOUSE:
EXTERIOR WALLS:
Wood Siding
Wood Shakes
Brick Veneer
Stone Veneer
Block
Vinyl Siding
Stucco on Frame
Aluminum Siding
Solid Stone
Solid Brick
Log
Other
If Other, please indicate:
ROOFING:
Asphalt Shingles
Wood Shakes
Wood Shingles
Slate
Tar & Gravel
Clay Tile
Copper
Rubber
Tin
Steel Roofing
FibreGlass
Other
If Other, please indicate:
DO YOU HAVE A SWIMMING POOL?
Yes
No
If Yes, is the pool
Above Ground
In Ground
Size of Pool:
DO YOU HAVE A FIREPLACE?
Yes
No
If Yes:
Single
Double
Triple
Gas
FIRE PROTECTION
IS THERE A FIRE HYDRANT WITHIN 1000 FEET OF THE HOUSE?
Yes
No
THE NEAREST FIREHALL IS
KMs AWAY, LOCATED IN
INFORMATION TO DETERMINE POSSIBLE DISCOUNTS
DATE OF BIRTH:
SPOUSE DATE OF BIRTH:
HAVE YOU HAD ANY CLAIMS IN THE PAST 5 YEARS?
Yes
No
Date & Description:
List all CLAIMS, POTENTIAL CLAIMS or ACTIONS pending or brought against you or any employee in the last three years
HAVE YOU HAD PREVIOUS INSURANCE?
Yes
No
If Yes, indicate Company name:
Indicate policy number:
Expiry date:
SIGNATURE (ENTER YOUR NAME)
*
:
date signed
D
M
YEAR
