LPI Home Insurance Request Form

Please Note: This Application can be Saved while in progress by clicking on the Save button at the bottom of the Form. You will then be sent a link to the incomplete form so you can complete it at any time. There is no need to answer any questions which do not apply to you or your home.

Name*

Phone Number*

Email*

EmailTelephoneOther

YesNo

If yes, what is the name of your Broker?

Address of Subject Property:*

Mailing Address of Applicant (if different from above address):

Current Insurance Company's Name:*

Current Insurance Policy Number:*

Current Insurance Policy Expiry Date:*

Please Upload a Copy of Your Current Policy: (Optional)

Full Names and DOB of each Owner on Title: Name of Owner 1*

Date of Birth of Owner 1:*

Date

Name of Owner 2:

Date of Birth of Owner 2:

Date

Names and Birth Dates of any other Owners:

How many years have you had Home Insurance?

Have you made any claims in the last 10 years? If yes, please describe (dates and amounts of claims):

How many years have you lived at the subject address?

If you have rental suites, how many and what is the monthly rental income from each suite?

If you have a mortgage, who is the mortgage with, how much is owing on it and when does the current term end?

Do you conduct any business in your home other than incidental office use? If yes, please describe:

What is the square footage on the main floor?

What is the square footage on the upper floor?

What is the basement square footage?

Does the home have an alarm or other security system?

If yes, please describe the system:

Is the security system local or monitored?

Does the security system detect fire and burglary or just burglary?

What type of roof does the house have?

ElectricGasOther

If your home is over 25 years old and you have renovated or upgraded it, please answer the following questions. Was the roof replaced or repaired? If yes, please describe the work done and the year it was completed:

Was the plumbing updated? If yes, please describe the work done and the year it was completed:

Does the home contain any Poly-B plumbing (an early version of plastic piping)?

YesNo

If yes, when?

Does it have at least 100 Amp service for the circuit breakers?

Is there any knob and tube wiring? If yes, please describe:

Has the heating system been updated? If yes, please describe the work done and the year completed:

How old is the hot water tank?

YesNo

PLEASE READ BEFORE SIGNING: A claim will become invalid and the insured’s right of recovery is forfeited 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 (b) the insured fails to provide material changes to these facts during the term of this contract; or (c) the insured contravenes a term of the contract or commits a fraud; or (d) the insured willfully makes a false statement in respect of a claim.

The applicants have reviewed all parts and statements 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.

The personal information provided in this document and in the future including, but not limited to, credit information and claims history may be collected, used and disclosed by the insurance representative or Insurance company, subject to local legislation, for the purpose of communicating with the insured or the representative, assessing the application for insurance and underwriting any such policies, evaluating claims, detecting and preventing fraud, and analyzing business results.

Please Note: insurance is not in effect until a binder or policy has been issued by an insurer and signed by all applicants.

YesNo

Signature Owner 1

Signature Owner 2

Signature Owner 3