Insurance Application

Applicant's Full name
Policy Type Required: Homeowners
Condo Owner Tenants Rented Dwelling
Applicant's Full Postal Address


Date Coverage Required: | | (YYYY | MM | DD)
Residence Telephone
Business Telephone
Fax Number
Email
Applicant Details
Occupation Date of Birth | | (YYYY | MM | DD)
Occupation Date of Birth | | (YYYY | MM | DD)
Have You Changed Address In The Last 3 Years Yes No
If Yes, please provide previous address
Years at Present Address Do you have any roommates, roomers or boarders #
Loss & Policy History
Have there been any losses or claims by the applicant or other members of applicant’s household in the past 5 years Yes No
if Yes please provide details

Has any insurer cancelled, declined or refused to renew or issue insurance to the applicant in the past 5 years Yes No
if Yes please provide details

Name of previous Insurer & Policy Number Expiry Date | | (YYYY | MM | DD)
Building Details
Year Dwelling Built Number of Stories Construction Floor Area
Heating Fuel Number of Families
 
Is there a Mortgage on the home
Interior Sprinklers
Burglar Alarm System
( Fire Alarm included Yes No ) 		Yes No
Yes No
Yes No
if Yes, is it Monitored Yes No –
Monitored by -
Make & Model of Alarm - 		Smoke Detectors
Active Block
Watch Member 		Yes No
Yes No
Coverages
Building $ Personal Property $ Legal Liability $
Additional Coverages: Earthquake Yes No Sewer Backup Yes No
All policies have limitation on the following items, if they exceed the following amount they should be specifically scheduled on the policy.
Jewelry Yes No      if Yes what is the Value $ (policy limits range from $2,000 to $6,000 depending on the insurer)
Furs Yes No           if Yes what is the Value $ (policy limits range from $2,000 to $6,000 depending on the insurer)
Bicycles Yes No     if Yes what is the Value $ (policy limits range from $2,000 to $6,000 depending on the insurer)
Coin & Stamp Collections, Silverware, Fine Arts, Cameras, Sports Equipment, Portable Computers, Musical Instruments can be added to the policy, please ask for details.
Payment Options: Monthly Payment Plan Yes No

Choose your recipient Nakamun Office: