Applicant Name Co Applicant Name
Mr.:
Mr.:
First Name:
First Name:
Last Name:
Last Name:
New Residence Information
Address:
Unit Number:
City:
Postal Code:
Telephone Home:
Telephone Work:
Telephone Cell:
Email Address:
Effective Date (coincides with Occupancy Date). Policies are issued for a one-year term:
Previous Residence Information
Applicant Information: Co Applicant Information:
Previous Address:
Previous Address:
Previous City:
Previous City:
Previous Unit Number:
Previous Unit Number:
Previous Postal Code:
Previous Postal Code:
Applicant Information
Date of Birth:
Occupation:
Employer:
Years Continuously Employed:
Number of unrelated people (not family members) that will be living in your unit:
Insurance History
Previous Insurer:
Policy Number:
Loss & Policy History (Last 5 Years):
Has any insurer cancelled, refused or declined coverage in the last 5 years?: Yes:
Coverage Details
Please Choose the appropriate Location and the amount of coverage desired. Based on $1000 deductible.
Will you require extra coverages (Jewellery, Home Business, Watercraft, Identity Theft etc?: Yes:
Premium Calculation:
The premium will be calculated using the base premium, applying the factor for the $1000 deductible (if selected),
deducting the net discount after adding the applicable discounts shown above, and adding $15 for the sewer back-up coverage.
8% Provincial tax applies to this estimated total. If you opt for the Three Pay Plan, a $35 Service Fee is added to arrive
at your Total Estimated Cost.
Signatures:
Where an applicant for this contract give false particulars to the prejudice of the Insurer or knowingly misrepresents or fails
to disclose any fact in any part of this application to the be stated herein, or the Insured contravenes a term of this contract
or commits a fraud, or the Insured willfully makes a false statement in respect of a claim, a claim will become invalid and the
Insured's right to recovery is forfeited. The Applicants have reviewed all parts and attachments 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. I have provided personal information in this document and otherwise and I may in the future provide further
personal information. Some of the personal information may include, but is not limited to, my credit, information and claims history.
I authorize my broker, insurance company and Minto Developments Inc. to collect, use and disclose personal information as permitted
by law and for the purposes necessary to underwrite, investigate and settle claims, detect and prevent fraud, validate information
provided, and exchange information with other property and casualty insurance companies, assessors, valuators, and other insurance
related service or information providers. I confirm that all individuals whose personal information is contained in this document
have authorized that I agree to the above on their behalf.
Payment Options:
Please select your preferred payment option.
Option 1:
Pay in full by credit card: Option 2:
Option 3:
(a 3% service charge applies) Balance
of payments automatically withdrawn from
your account in equal monthly instalments.
A notice listing your monthly payments will
be attached to your policy.
