Residential Condo Questionaire
Name of Insured (s) : List all people on title of the property)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Insured #2 (s) : List all people on title of the property)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Insured #3 (s) : List all people on title of the property)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Insured #4 (s) : List all people on title of the property)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Format: (000) 000-0000.
Home Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
What is your Occupation? Years Continuously Employed?
*
Occupation
Years Employed
Have you changed your address in the last 3 years? If yes please provide your previous address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any claims in the past 5 years?
*
Please Select
yes
No
If yes, please explain
If you had a claim, please explain.
Purpose of property?
*
Please Select
Primary
Rental
Other (Please specify...)
Other
Please specify the purpose of property
Any Business Activities on the premises?
*
Please Select
Yes
No
Other (Please specify...)
Other
Please explain the Business Activity
How many years have you had continuous insurance?
*
Contents Limit Requested
*
Consent to soft credit checks
*
Please Select
Yes
No
What year was the building built?
*
Type of Building?
*
Please Select
Detached Home
Townhouse
Apartment
Type of heating?
*
Is building sprinklered?
*
Please Select
Yes
No
Number of Families
*
Please Select
1
2
3
4
5
Has any insurer Cancelled, Declined, Lapsed or refused to Renew to you in the past 5 years?
*
If yes please explain down below
If yes, please explain
Please upload Strata Documents
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Feedback about us:
Suggestions if any for further improvement:
Will you be willing to recommend us?
Yes
Maybe
No
Please give reference of any two people whom you feel:
Rows
Full Name
Address
Contact Number
1
2
Submit
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