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Fields marked with * are mandatory fields.
Home Phone Number*
Work Phone Number
Best Time To Contact Me*
Morning at workAfternoon at workEvening at workMorning at homeAfternoon at homeEvening at home
Mailing Address (PO BOX)*
HomeownersCondominiumRentersSecondary homeRental property
Number of Outer Walls
Number of Inner Walls
Number of Windows
Number of Roofs
Number of Floors
Number of Storeys
Are the buildings and or out buildings within 20ft of another building
How is it constructed?
For what purpose is it used?
Is any business/ profession/ trade carried on in the dwelling or in any portion of the premises of which the dwelling forms a part?
How old is the building
How big is the building (Sq ft)
Year built / renovated
Details of burglary protection
Are the Buildings in a good state of repair and will they be so maintained?
What is the occupancy type?
Premises Occupied by
Number of Tenants, lodgers, boarders or paying guests:
For how many days (consecutive) will the dwelling be left without an inhabitant in any one year?
General Contents - Value
Electronic Equipment (Television sets, DVD players, Stereos, Internal Satellite) Value:
Computer Equipment Value:
(Break-down will be required)
(Valuation will be required)
Has any Company or Insurer, in respect of any of the contingencies:
Declined to insure you Required special terms to insure you Cancelled/refused to renew your insurance None of the above
If YES, please give full particulars:
Have you any other policies in force covering any of the contingencies to be insured against?
Have you sustained any losses during the past 3 years?
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