Tenants Form

LPI Tenant and / or Condo Insurance Application
Title:
First Name: *
Last Name: *
Middle Initials:
Date of Birth:
Address: *
City: *
Province/State:
Postal Code:
Phone: *
E-mail: *
Risk Location Address, if different from above:
Postal Code:
Occupation:
Employer:
How is your non auto-related claims history during past 5 years? (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:
How many years have you had home insurance?
Age of Building:
Ground floor area Sq. Ft.:
Total Sq. Footage:
What type of residence is this? (check all applicable):	Detached Semi-Detached Townhouse Rowhouse Prefab 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 restaurant or other business in your building?	Yes No Other
Please specify:
Fire Protection
	Unprotected from Fire Risk Within 300 meters of Hydrant Within 5 km of Firehall Within 8 km of Firehall
Name of Firehall:
Type of Construction
	Brick Woodframe Cement Masonry Stone Steel Brick Veneer
Fire Resistive Buildings (including floors)
	Concrete Structure Brick Structure Masonry Structure
Security System
Fire Detection:	Yes No
Monitored:	Yes No
Local:	Yes No
Monitored by:
Burglar Alarm:	Yes No
Monitored:	Yes No
Local:	Yes No
Monitored by:
Sprinkler:	Yes No
Smoke detector:	Yes No
Other security:
Heating System
If Furnace (Central):	Gas Oil Wood Electric
If other Heating System, which:	Radiant Heat (hot water) 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 LPI 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
If other, please specify:
Age in Years:
Additional Liability Exposure Information
Daycare on Premises:	Yes No
Number of Children:
Incidental Office Use:	Yes No
Is their a business on this premises?	Yes No
Any other income producing activites?	Yes No
If yes to either of the two above questions, Please Specify:
Is there a co-occupant who requires coverage?	Yes No
If yes, please have co-occupant fill out this form as well.
Do you rent rooms to others?	Yes No
Are there additional families living with you?	Yes No
Is watercraft coverage required?	Yes No
If yes please fill out marine insurance application as well and send it to us.
Additional Coverage:	Earthquake Claims free discount protection Identity theft
Scheduled Personal Property Summary. Appraisals may be required for some 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 (Please Specify)
Above details are adequate for an estimate.To bind your Home Insurance Policy the following details will be required on all items (where available).
Serial No., Identification No., Purchase / Appraisal Date:
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.