| 1. | Number of automobiles owned, leased or regularly used by the applicant (including private passenger vehicles licensed in a company name and that are provided for applicant for personal use) | |
| 2. | Do the primary Automobile Policies listed above cover all these automobiles? | |
| 3. | Does any driver of the above automobiles have 5 or more demerit points? | |
| 4. | Has any driver of the above automobiles had their license suspended or cancelled in the last 5 years? | |
| 5. | Number of recreational motor vehicles owned, leased, or operated: | |
| 6. | Do the primary Automobile Policies listed above cover all these recreational motor vehicles? | |
| 7. | Number of Residences Farms Rental Units
Parcels of Vacant Land owned or occupied by applicant. | |
| 8. | Does the primary Personal Liability cover all these locations? | |
| 9. | Details of all watercraft owned, hired, or regularly used by the applicant: | |
| 10. | Do the primary Liability policies shown cover all watercraft? | |
| 11. | Provide details of any restrictions of coverage (ie: no waterskiing, territorial limitations, etc.) | |
| 12. | Is any watercraft operated outside of Canadian Waters? | |
| 13. | Is the above watercraft used solely for private and pleasure purpose? | |
| 14. | Do any of the premises contain an office premise or business operated by the applicant? | |
| 15. | Do any of the primary Liability Policies have any other coverage restrictions added to the standard wordings?
If yes, please advise details: | |
| 16. | Loss History: Has the applicant (s) or any resident (s) of the household experienced any loss which has been paid or reserved in an amount of $5,000. or more?
If yes, please advise details: | |
| 17. | Does the applicant own any property, watercraft or automobiles that are located outside of Canada?
If yes, please advise details: | |
| 18. | Limit Desired | |
| 19. | Has any Insurer within the past 5 years declined, cancelled or refused any form of insurance for the applicant as defined? | |
