HABITATIONAL INSURANCE APPLICATION

1 HABITATIONAL INSURANCE APPLICATIONCSIO - HABITATIONAL INSURANCE APPLICATION CA2001e 201504 2015, Centre for Study of INSURANCE Operations. All rights METHODINSURANCE COMPANYQUOTENEWRENEWALBINDER NUMBERPOLICY 'S FULL NAME AND POSTAL ADDRESSNAMEADDRESSCITY, PROVPOSTAL CODECONTACT NAMEHOMECELLBUSINESSFAXEMAILWEBSITEPREFE RRED 'S NAME AND POSTAL ADDRESSNAMEADDRESSCITY, PROVPOSTAL CODECONTACT NAMEBUSINESSCELLEMAILBROKER CONTRACT NO. BROKER SUB-CONTRACT NO. BROKER CLIENT ID COMPANY CLIENT IDGROUP NAMEGROUP PERIODEFFECTIVE DATEYYYYMMDDAT 12:01 TIMES ARE LOCAL TIMES AT THE APPLICANT'S ADDRESS SHOWN DATAAPPLICANT 1 NAMEOCCUPATIONYEARS CONTINUOUSLY EMPLOYEDDATE OF BIRTHYYYYMMDDAPPLICANT 2 NAMEOCCUPATIONYEARS CONTINUOUSLY EMPLOYEDDATE OF HISTORYCLAIMS HISTORY REPORT DATEYYYYMMDDHAVE THERE BEEN ANY LOSSES OR CLAIMS BY THE APPLICANT IN THE PAST 5 YEARS?

2 YESNOIF YES, COMPLETE THE TABLE OF LOSS YYYYMMDDLOC. OF LOSSSTATUSAMOUNT PAIDINSURANCE COMPANYPOLICY NUMBEROPENCLOSEDOPENCLOSEDOPENCLOSEDOPEN CLOSEDDOES THE APPLICANT HAVE ANY KNOWLEDGE OR INFORMATION OF ANY FACT, CIRCUMSTANCE, OR SITUATION WHICH COULD REASONABLY GIVE RISE TO A CLAIM WHICH WOULD FALL WITHIN THE SCOPE OF THE PROPOSED INSURANCE ?YESNOIF YES, PROVIDE DETAILS IN THE REMARKS HISTORYCONTINUOUSLY INSURED SINCEYYYYMMDDFIRST TIME INSURED, NO PRIOR HABITATIONAL INSURANCEINSURANCE COMPANYPOLICY NUMBEREFFECTIVE DATE YYYYMMDDEND DATE YYYYMMDDREASON FOR ENDINGIF TERMINATED BY INSURER, REASONIN THE PAST FIVE YEARS, HAS ANY INSURANCE COMPANY DECLINED, CANCELLED, REFUSED, OR INDICATED AN INTENT NOT TO RENEW ANY HABITATIONAL INSURANCE POLICY?

3 YESNOIF YES, PROVIDE DETAILS IN THE REMARKS REFERENCE INFORMATIONLIST OTHER POLICIES WITH THIS INSURANCE COMPANYLINE OF BUSINESSPOLICY NUMBERLINE OF BUSINESSPOLICY NUMBERLINE OF BUSINESSPOLICY NUMBERLINE OF BUSINESSPOLICY NUMBERPage 1 HABITATIONAL INSURANCE APPLICATIONCSIO - HABITATIONAL INSURANCE APPLICATION CA2001e 201504 2015, Centre for Study of INSURANCE Operations. All rights INFORMATION LOC. TABLETOWN ID CODENO. OF ADDRESSSAME AS POSTAL ADDRESSADDRESSCITY, PROVPOSTAL INFORMATIONYEAR BUILTNO.

4 OF STOREYSNO. OF FAMILIESNO. OF UNITSTOTAL LIVING AREA (excluding basement)sq ftm2 ACCESS TYPESMOKERS?YESNOREPLACEMENT COST EVALUATOR PRODUCTDATE EVALUATION COMPLETEDYYYYMMDDDATE OF BIRTH OF ELDEST OCCUPANTYYYYMMDDRELATIONSHIP TO APPLICANTOCCUPANCY TYPESTRUCTURE TYPEFOUNDATION TYPEFINISHED BASEMENT%EXTERIOR WALL FRAMING TYPEEXTERIOR WALL FINISH TYPEINTERIOR WALL CONSTRUCTION TYPE%%%INTERIOR WALL HEIGHTftm%ftm%ftm%INTERIOR FLOOR FINISH TYPE%%%CEILING CONSTRUCTION TYPE%%%UPGRADESFULL (YY)PARTIAL (YY)ROOFELECTRICALHEATINGPLUMBINGROOF COVERING TYPEELECTRICAL WIRING TYPEELECTRICAL PANEL TYPESERVICEAPRIMARY HEATING TYPEAPPARATUSFUELLOCATIONPROFESSIONALLY INSTALLED?

5 YESNOAPPROVED BY ULC, CSA, OR WH?YESNOAUXILIARY HEATING TYPEAPPARATUSFUELLOCATIONPROFESSIONALLY INSTALLED?YESNOAPPROVED BY ULC, CSA, OR WH?YESNONO. OF FACE CORDS PER YEARSOLID FUEL HEATING QUESTIONNAIRE ATTACHEDRADIANT HEATING AREAsq ftm2 MAKEYEAROIL TANK YEARINSIDEOUTSIDEIN GROUNDABOVE GROUNDFUEL OIL TANK QUESTIONNAIRE ATTACHEDPLUMBING TYPECOPPER%GALVANIZED%ABS%PVC%PEX%POLY-B %LEAD%%WATER HEATER TYPEAPPARATUSWATER HEATER YEARFUELPROFESSIONALLY INSTALLED?YESNOAPPROVED BY ULC, CSA, OR WH?YESNOPRIMARY WATER MITIGATION TYPESUMP PUMP TYPEAUXILIARY POWERBACK UP VALVEAUXILIARY WATER MITIGATION TYPESUMP PUMP TYPEAUXILIARY POWERBACK UP VALVEMAIN WATER VALVE SHUT OFF TYPENO.

6 OF MAIN WATER VALVE SHUT OFF SENSORSSEWER BACKUP QUESTIONNAIRE ATTACHEDFIRE PROTECTIONDISTANCE TO HYDRANTHYDRANT TYPEDISTANCE TO RESPONDING FIRE HALLFIRE HALL NAMESECURITY SYSTEMFIREBURGLARYSMOKE DETECTORSSMOKE DETECTOR TYPENO. OF DETECTORSIF ANY OF THE ABOVE ARE MONITORED, MONITORED BYALARM CERTIFICATE ATTACHEDPREMISES ACCESS SECURITY TYPEHOME SPRINKLERED?YESNOBATHROOMSNO. OF FULLNO. OF HALFKITCHENSNO. OFKITCHEN #1 QUALITYKITCHEN #2 QUALITYGARAGE/CARPORTNO. OF CARSGARAGE TYPESWIMMING POOLYEARPOOL TYPEPOOL FENCED?

7 YESNOPage 2 HABITATIONAL INSURANCE APPLICATIONCSIO - HABITATIONAL INSURANCE APPLICATION CA2001e 201504 2015, Centre for Study of INSURANCE Operations. All rights INFORMATION LOC. OUTBUILDINGS/STRUCTURES (Additional limits may be required on any heated outbuildings) TYPEEXTERIOR WALL FRAMING TYPEHEATING APPARATUS TYPEFUEL TYPETOTAL AREAVALUE1sq ftm22sq ftm23sq / LOSS OF INTERESTADDRESSCITY, PROV/STATEPOSTAL/ ZIP OF INTERESTADDRESSCITY, PROV/STATEPOSTAL/ ZIP OF INTERESTADDRESSCITY, PROV/STATEPOSTAL/ ZIP COMPLETED YYYYMMDDDESCRIPTIONDATE COMPLETED HISTORYOCCUPANCY DATE FOR THIS LOCATIONYYYYMMDDIF OCCUPANCY IS LESS THAN 3 YEARS.

8 PROVIDE PREVIOUS ADDRESSES CODEDATE MOVED IN YYYYMMDDDATE MOVED OUT EXPOSURESAll YES answers may require liability extension coverage or remarks explaining coverage YOU OWN/RENT MORE THAN ONE LOCATION? OF WEEKS LOCATION RENTED TO OTHERS? OF ROOMS RENTED TO OTHERS? OPERATION - NUMBER OF YOU OWN A TRAMPOLINE? YOU HAVE A GARDEN TRACTOR? YOU HAVE A GOLF CART? OF SADDLE/DRAFT ANIMALS? YOU OWN ANY UNLICENSED RECREATIONAL VEHICLES? ENERGY INSTALLATION ON PREMISES? YOU OWN ANY WATERCRAFTS? OF FULL TIME RESIDENCE EMPLOYEES?

9 THERE A CO-OCCUPANT THAT REQUIRES COVERAGE?YESNOCO-OCCUPANT THERE ANY KIND OF BUSINESS OPERATION?YESNOIF YES, DESCRIBE OF DOGS IN THE HOUSEHOLD?BREED(S) OF PROPERTY AREA (if greater than 1 acre)acreshectaresOTHER 3 HABITATIONAL INSURANCE APPLICATIONCSIO - HABITATIONAL INSURANCE APPLICATION CA2001e 201504 2015, Centre for Study of INSURANCE Operations. All rights AND LIABILITY EXTENSIONS LOC. FORM TYPERATING PLANCOVERAGE DESCRIPTIONREQUESTED / DECLINEDAMOUNT OF INSURANCEDEDUCTIBLEDEDUCTIBLE TYPETYPE OF12345 ESTIMATED PREMIUMDWELLING BUILDINGREQUESTEDDECLINEDDETACHED PRIVATE STRUCTURESREQUESTEDDECLINEDPERSONAL PROPERTYREQUESTEDDECLINEDADDITIONAL LIVING EXPENSESREQUESTEDDECLINEDLEGAL LIABILITYREQUESTEDDECLINEDVOLUNTARY MEDICAL PAYMENTSREQUESTEDDECLINEDVOLUNTARY PROPERTY DAMAGEREQUESTEDDECLINEDSEWER

10 BACKUPREQUESTEDDECLINEDREQUESTEDDECLINED REQUESTEDDECLINEDREQUESTEDDECLINEDREQUES TEDDECLINEDREQUESTEDDECLINEDREQUESTEDDEC LINEDREQUESTEDDECLINEDREQUESTEDDECLINEDR EQUESTEDDECLINEDREQUESTEDDECLINEDREQUEST EDDECLINEDREQUESTEDDECLINEDESTIMATED PREMIUM FOR THIS EXTENSIONS AND EXCLUSIONSLIABILITY COVERAGE DESCRIPTIONREQUESTED / DECLINEDAMOUNT OF INSURANCEDEDUCTIBLEDEDUCTIBLE TYPETYPE OF12345 ESTIMATED PREMIUMREQUESTEDDECLINEDDECLINEDREQUESTE DDECLINEDREQUESTEDDECLINEDREQUESTEDESTIM ATED PREMIUM FOR THIS AND SURCHARGESDISCOUNT/SURCHARGE DESCRIPTION%APPLIED TO PREMIUM?