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Home Insurance by Co-operators

Home Insurance - Homeowners Application Form
Please take a few minutes to fill out this form.

Field with " * " - must answer before you submit your application.

1st owners full name:*

1st owners DOB:*

2nd owners full name:

2nd owners DOB:

Company’s full legal name or operating name (if the property owned by an entity):

Email Address*

Primary Contact Phone:*

Secondary Contact Phone:

Address of location to be insured if different from mailing address:

Consent for a soft credit score (This doesn’t affect your credit score & gives an additional discount.)*

Is there previous Insurance?*

Have you experienced any claims in the last 5 years? *

Is there a mortgage or secured line of credit?*

Do you have mortgage insurance?*

Have you experienced insurance canceled?*

Any smokers residing in the unit?*

Is there Farming Activity?*

A swimming pool?*

Guard dogs?*

Any business activity*

Year the dwelling built?*

Building style:

Is any portion being rented to others?*

Any short term rentals?*

Building construction:

Building foundation:

Is there a basement?*

If "Yes", is it finished?

Total sqft (excluding basement)?*

Is there an attached garage?*

How many cars?

Do you have a monitored alarm system?*

Age of hot water tank?

Where is your washing machine located?

# of kitchens. (custom, semi custom, builders grade)*

# of bathrooms and half bathrooms. *

Length of time you have lived at this location:

Sump pump:*

Earthquake insurance?*

Building located on leased land?*

Building is vacant?*

Underground oil tank on property?*

Any past or present marijuana growing operation?*

Fire hydrant within 300m?*

Fire hall within 13km?*

Type of wiring?

If upgraded, what year?

Type of plumbing:

Year upgraded?

Type of roof:

When was the roof updated?

What kind of heating systems?

Any wood stoves?*

Date of Submission:*

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