|
|
Name
of applicant:
(include the corporate or Quebec Inc name) |
|
| First
name of applicant : |
|
Postal
address:
(include the postal code) |
|
| Telephones: |
|
| Email: |
|
| Date
of birth: |
|
Co-owners,
if any:
(name and provide above details) |
|
Name
of the company, if any:
(including if numbered company) |
|
Present
insurer:
(name of the insurance company,
policy number and expiry date) |
|
| Distance
to a fire hydrant: |
|
| Distance
to a fire department: |
|
| Criminal
Antecedents: |
|
Claims
or incidents in past 6 years:
(whether you were the owner
or not) |
|
Address
of the property:
(if
different from the above address) |
|
Describe
the building:
(appartment block, commercial,number
of stories, etc.) |
|
Type
of construction:
(frame with brick siding,
steel,concrete
blocks, etc.)
|
|
Details
of tenants:
(beauty parlour, family restaurant,
number of appartments, etc.) |
|
Kind
of heating:
(oil furnace, electric baseboards,
hot water, suspended heating units, etc.)
|
|
Neighbouring
buildings and businesses:
(describe the buildings and
businesses ) |
|
Distances
to these other buildings:
(specify in number of feet) |
|
Restaurants
or bars in proximity:
(provide details in radius of 1000 feet) |
|
Cancellation
or non-renewal of an insurance policy in
the past:
(provide the details in Special
considerations, if applicable) |
|
Coverages
desired:
(minimum deductible of $500
for A,B,C,D)
|
|
| Amounts
desired: |
|
| Deductible
desired: |
|
Name
and address of mortgagee:
(include the postal code)
|
|
| Current
amount of the mortgage: |
|
| Special
considerations: |
|
| Digital
photos: |
|
|
|
|
