Red River College (Student Residency) - TENANT INSURANCE
Insurance made available by Western Financial Group through this Tenants Insurance Application is underwritten by Intact Insurance.
Insured 1
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First Name
Last Name
Student #
*
Date of Birth
*
-
Month
-
Day
Year
Date
*
Smoker
Non Smoke
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Effective Date Required
*
-
Month
-
Day
Year
Date
Mailing Address
*
Street Address
Unit #
City
Province
Postal Code
What is the amount of coverage you require for your personal belongings(contents)?
*
Minimum amount of coverage that comes with the policy is $25,000. If you require more than $25,000 please indicate the amount above.
What Deductible Would You Like?
*
$1000
What limit of liability Insurance Would You Like?
*
$1,000,000
Exterior of Building
Stucco
Brick
Wood
Vinyl
Stone
Year Built
Construction Type:
Wood Frame
Masony
Concrete Block
Fire Resistive
Steel
Type of Dwelling & Size
*
Condo/Apartment
Duplex
Side by Side
Townhouse
Row House
Detached Dwelling
Other
Bi-Level
Tri-Level
High Rise
If other please provide details:
How many stories?
*
How many units?
*
What floor is your unit on?
*
Primary Heating System
Electric Furnace
Gas Furance
Electric Baseboard
Wood
Radiant
Water
Geotheramal
Security Systems
Centrally Monitored for Burglary and Fire
Monitored for Burglary Only
Monitored for Fire Only
Local Alarm
Water Sensor
Controlled entrance to the building and 24-hours security guard/patrols
Controlled entrance to the building and an electronic pass system to designated area
24-hours Gated Community
Equipped with in suite sprinklers
None
Do you have any belongings, which may require special insurance? (Such as bicycles, jewellery, furs, collections and watercraft) If so please indicate.
Has any insurer cancelled, declined, refused to renew or issue habitational insurance in the last 5 years:
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Yes
No
Provide Details of any claims. (Date of Loss, Cause of Loss, Amount Paid, Insurance Company)
I agree that I have provided Western Financial Group Inc. and its affiliates(“Western”) with personal information about me which may be collected, used and disclosed for the purposes of (1) contacting me to obtain additional information and to assess my insurance needs; (2) recommend relevant financial and/or insurance products or services to me; (3) provide financial and/or insurance products and services requested by me; (4) evaluate and investigate claims; and (5) meet legal and regulatory requirements applicable to Western’s operations (collectively referred to as the “Purposes”). I also agree and authorize Western Financial Group to share personal information with third parties as necessary for the Purposes. For more information about the collection,use or disclosure of your personal information by Western Financial Group,please refer to our Privacy Statement at www.westernfinancialgroup.ca under Privacy/Legal.
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Yes
No
In respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may order inspection and previous insurer reports containing personal, credit, and investigative information. Do you authorize us to collect, use and disclose to appropriate third parties, this information solely relating to your automobile and/or personal property policy for the purposes necessary to assess the risk, investigate and settle claims and detect and prevent fraud?
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Yes
No
I understand that my policy will be mailed or emailed directly to me. I hereby consent to Western Financial Group, providing Red River College with a copy of my Certificate of Insurance, if requested, or such other proof of insurance coverage as may reasonably be required pursuant to the Red River College student residence contract.
*
Yes
No
I consent to Western Financial Group, sending me commercial electronic messages regarding this application and other offers related to its financial and/or insurance products and services. I understand that I may unsubscribe from receiving these commercial electronic messages at any time by contacting Western Financial Group at: Email info@westernfg.ca or in writing to: 1010 – 24th Street S.E., High River Alberta, T1V 2A7.
*
Yes
No
I agree to pay the required annual policy premium, due in full at policy inception.
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Yes
No
I understand that coverage does not automatically transfer if I move out of residency at Red River College. I must inform Western Financial Group if I move out of residency and wish to transfer my policy to a new location – otherwise my coverage will lapse on expiry.
*
Yes
No
Submit
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