LPI Universal Home Insurance Application Title: Mr. Mrs. Ms. Dr. First Name: * Last Name: * Middle Initials: Date of Birth: Address: * City: * Province/State: AB BC MB NB NL NT NS NU ON PE QC SK YT Washington, US Postal Code: Phone: * E-mail: * Risk Location Address, if different from above: Postal Code: Occupation: Employer: Years Continuosly Employed: Have you changed addresses in the last 5 years? Yes No How is your Insurance History? (Check all Applicable): No Losses or Claims 1 Loss Or Claim 2 or more Losses or Claims Insurance has been Cancelled Insurance has been Refused Name of Previous Insurer: Policy Number: Expiry Date: List all Mortgage Holders (Loss Payees): How many years have you had home insurance? Age of Building: Ground floor area Sq. Ft.: Total Sq. Footage: If the home to be insured is over 25 years old please provide the following information: Has there been any renovations or upgrades? Yes No Was it a partial or complete renovation? Partial Complete What year was renovation completed? Has your heating system been upgraded? Yes No Was it a partial or complete renovation? Partial Complete Year Upgraded: Has the roofing been upgraded: Yes No Was it a partial or complete renovation? Partial Complete Year upgraded: Has your plumbing been upgraded? Yes No Was it a partial or complete renovation? Partial Complete What type of plumbing do you have? Copper Plastic Other Percentage of Copper: Percentage of Plastic: Percentage of Other Materials: Was it a partial or complete renovation? Partial Complete Has your electrical system been upgraded? Yes No Was it a partial or complete renovation? Partial Complete Year Upgraded: Does your electrical system have: Breakers Fuses 100 Amps 200Amps Other: Please describe all partial upgrades and indicate what year the work was done: What type of residence is this? (check all applicable): Primary Secondary Seasonal Rental Vacant Unoccupied Under Construction Detached Semi-Detached Townhouse Rowhouse Pre. Fab Mobile Home Park Code Other Number of stories: Appartments and Number of Units: Duplex Triplex Multiplex Basement Suite Less than 6 Units More than 6 Units Is there a business on this premises? Yes No Other If so, please specify what type of business: Fire Protection: Unprotected Within 300 meters of Hydrant Within 5 km of Firehall Within 8 km of Firehall Name of Firehall: Construction: Brick Woodframe Cement Masonry Masonite Stone Steel Brick Veneer Fire Resistive Buildings: Concrete Structure Brick Structure Masonry Structure Security System Fire Detection: Yes No Monitored by: Burglar Alarm: Yes No Monitored by: Sprinkler: Yes No Smoke Detector: Yes No Other security: Heating System If Furnace (Central): Electric Gas Oil Wood If other Heating System, Which: Radiant Heat Space Heater Oil Stove Wood Stove Wall Furnace Electric Radiant Heat in Ceiling Electric Heat If Electric Radiant Heat, Size: Year: Make: Secondary Heat Source: Woodburning Unit Fireplace Insert Solid Fuel Heating Unit If you have a Solid Fuel Heating Unit please fill out Solid Fuel Questionnaire in our Apply Online Section and submit it to us. ULC, CSA, WH or ACNOR Approved: Yes No If you have an Oil tank is it: Inside Outside Above Ground In Ground Age in Years: If other, please specify: Additional Liability Exposure Information Is this location rented to others? Yes No How long has it been rented? Saddle/Draft Animals on premises: Yes No Number of Animals: Additional Residences/Properties: Yes No Number of Units: Buildings Under Construction: Yes No Daycare on Premises: Yes No Number of children: Are there any other income producing activites on this premises? Yes No If yes to either of the two above questions, Please Specify: Is there a co-occupant who requires coverage? Yes No If so please have co-occupant fill out and subit this application as well. Is watercraft coverage required? Yes No If yes please fill out our Marine Insurance application on our Marine page and submit it to us. Additional Coverage: Earthquake Claims Free Discount Protection Identity Theft Outbuilding Details (Describe Usage, Construction and Heat): Scheduled Personal Property Summary. Appraisals may be required for some items: Personal Items: Jewelry Furs Silverware Coins Stamps Fine Arts Breakage Cameras Computers for Work Personal Computer Musical Instruments Sports Equipment Bicycles Firearms Tool Floater Office Equipment Other If Other, please specify: Above details are adequate for estimates only. To bind your Home Insurance Policy the following information will be required (where available). Your description should include Serial No., Identification No., Purchase / Appraisal Date of all items in above schedule: Please specify items for business or professional use: Add me to LPI Mailing List: Yes Comments Regarding your Request:   Disclaimer: This Online form is for estimates only and does not constitute a binding agreement. One of our qualified representatives will contact you for additional information that may be required and to provide you with a quote.