• CLIENT INFORMATION

  • Date of Birth Applicant #1:*
     / /
  • Date of Birth Applicant #2:
     / /
  • Do you consent for Underwriters to undergo a soft credit check on your account, as they may offer a more favourable premium with this obtained:*

  • POLICY INFORMATION

  • Insured Risk:*
  • Policy Deductible:*
  • Liability Limit:*
  • Earthquake Coverage:*
  • Have you been cancelled, refused, or declined coverage insurance in the past five (5) years:*
  • Any Claims in the Past Five (5) Years?*
  • Date of Loss:
     / /

  • BUILDING INFORMATION

  • Exterior Walls:*

  • Loss Prevention:
  • Type of Alarm System:
  • Loss Prevention:

  • ADDITIONAL INFORMATION

  • Non Smoker:*
  • Legal Suite:*
  • Home Business:*
  • Swimming Pool:*
  • Oil Tank on Property:*
  • Wood Stove:*

  • SIGNATURE AND REVIEW

  • How did find us:

  • Are you interested in other niche insurance products Dolphin Insurance specializes in?

  • I understand that the above information is correct and complete to the best of my knowledge, is to be the bases of this insurance, if granted, but does not obligate me to accept the insurance nor for the company to accept the risk.

  • Date*
     - -

  • Where (a) an Applicant for this contract gives false particulars to the prejudice of the insurer or knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or the Insured contravenes a term of the contract or commits a fraud; or (c) the Insured willfully makes a false statement in respect of a claim, a claim will become invalid and the Insured’s right to recovery is forfeited. The Applicants have reviewed all parts and attachments of this application and acknowledge that all information is true and correct and understand that this application for insurance is based on the truth and completeness of this information. I have provided personal information in this document and otherwise and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker’s or insurance company’s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.

  •  
  • Should be Empty: