Polo Park Condo Insurance Questionnaire

Western Financial Group is a diversified insurance services company that is focused on creating security and has provided over one million Canadians the right protection for more than 100 years. Headquartered in High River, Alberta, Western provides personal and business insurance through 179 locations, its affiliates and a variety of connected channels, with an engaged team of approximately 1,800 people.

Western Financial Group is a subsidiary of Trimont Financial, a wholly-owned subsidiary of The Wawanesa Mutual Insurance Company.
Condo Insurance Questionnaire
Your privacy is important to us. In order to offer you products and services from our insurance partners, as well as submit claims and manage related inquiries, we will be collecting personal information from you. This information may be used by our external sources, including other property and casualty insurers or claims information databases. This may also be used in the prevention, detection and prosecution of fraud. In order to continue with this application, we require your consent to collect, use and disclose this information as reasonably required for the purposes I have described. You can review our privacy policy on the internet by going to www.westernfinancialgroup.ca Do we have your consent to use and share the personal information you will provide to us as described?*

YesNo
Legal name on title*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Legal name on title

First NameLast Name
Date of Birth

MonthDayYear
Date
Is anyone in your household a smoker?
Phone Number*

Area CodePhone Number
Email*
example@example.com
Effective Date Required*

MonthDayYear
Date
Legal Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Mailing Address (if different from legal address)

Street Address

Street Address Line 2

CityProvince

Postal Code
How long have you lived at the above address?*
Total number of years
If you have lived at this address for less than 3 years, what was your previous address?

Street Address

Street Address Line 2

CityProvince

Postal Code
In order to provide the most accurate quote, the insurance markets may
need to access your credit history information. Doing so may allow you to
obtain a lower quote for your insurance, however, not providing consent will
not prevent you from receiving a quote.
Do we have your consent to access and use your credit history information as described?*

YesNo
How many years have you held continuous insurance?*
Previous Insurer
Policy Number
Expiry Date

MonthDayYear
Date
Has any insurer cancelled, declined, refused to renew or issue habitational insurance in the last 5 years:*

YesNo
Provide Details of any claims. (Date of Loss, Cause of Loss, Amount Paid, Insurance Company)
What is the amount of coverage you require for your personal belongings(contents)?*
Minimum amount is $30,000
What Deductible Would You Like?*

$500$1000
Do you have a mortgage?

YesNo
Name of Mortgagee
Full Name of the Institution
Mortgagee Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Fire Protection - Is your residence within:*

1000 Feet of a fire hydrantWithin 13 km's of a fire hallUnprotected
Exterior of Building*

StuccoBrickWoodVinylStoneOther
Year Built*
Construction Type:*

Wood FrameMasonyConcrete BlockFire ResistiveOther
Type of Dwelling & Size*

Apartment styleDuplexSide by SideTownhouseSingle family homeHigh RiseOther
How many stories?*
How many units?*
What floor is your unit on?*
Roofing Material

Asphalt ShinglesMetal/AluminumSteelTinWood/Cedar ShakesSynthetic ShinglesTar/GravelOther
Year Roof Was Updated
Primary Heating System*

Electric FurnaceGas FuranceElectric BaseboardWoodRadiantWaterGeotheramalOther
Year Heating Was Updated
Plumbing Information - Please indicate the type of plumbing in your unit.

CopperPVCABSPEXLeadGalvanized SteelOther
Year Plumbing Was Updated
Electrical Wiring Information - Select all that apply

CopperAluminumKnob and tubeOther
Electrical Panel Information

FusesBreakersOther
Electrical Service Information

60 AMP100 AMP200 AMPOther
Year Electrical Was Updated
Do you require sewer back up coverage?*

YesNo
Sewer Back Up Protection

Sump PumpBack Water Valve (GATE)Back Water Valve (FLAPPER)None
A COMPLETED SEWER BACKUP QUESTIONNAIRE WILL BE REQUIRED AND SUBMITTED TO THE INSURANCE COMPANY FOR APPROVAL
Security Systems*

Centrally Monitored for Burglary and FireMonitored for Burglary OnlyMonitored for Fire OnlyLocal AlarmWater SensorControlled entrance to the building and 24-hours security guard/patrolsControlled entrance to the building and an electronic pass system to designated area24-hours Gated CommunityEquipped with in suite sprinklers24/7 recorded video surveillanceNoneOther
Do you have any belongings which may require increased coverage limits? (Such as bicycles, jewelry, furs, collections and watercraft) If so please indicate.
Do you operate a business inside or outside your home (Includes Daycare)?*

YesNo
If yes, please provide details of your business.
Do you have any roomers or boarders?*

YesNo
Number of cannabis plants grown on premises?*
Do you have any dogs?*

YesNo
What breed of dog?
Additional Notes:
Referred by Employee?
Please Provide First Name of Employee
We look forward to working on this home insurance quote for you. As part of the quoting process we are going to have a life insurance specialist contact you to go over options for coverage you may need when you purchase a home or have a mortgage.
Should be Empty: