LANDLORD PROTECTION

STAND ALONE APPLICATION

BROKER:Agent/Broker: Tel No.:

Address: Email:

APPLICANT:Name of Insured:

Mailing Address:

CURRENT PROPERTY CARRIER INFORMATION: Insurer(s): Policy No.: Expiring date:

Unit #1 / Unit #2 / Unit #3 / Unit #4 / Unit #5 / Unit #6
ABOUT EACH RENTAL UNIT
Address
Monthly rent
Type of rental / Long-term
Short-term
Student housing
Rooming house
Social housing / Long-term
Short-term
Student housing
Rooming house
Social housing / Long-term
Short-term
Student housing
Rooming house
Social housing / Long-term
Short-term
Student housing
Rooming house
Social housing / Long-term
Short-term
Student housing
Rooming house
Social housing / Long-term
Short-term
Student housing
Rooming house
Social housing
Unpaid rent or more than 2 weeks late during past 12 months? / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
ABOUT TENANTS
Signed lease / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
credit score at 620 or above / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know
Rent < 40% of tenant’s gross income / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know
1-month deposit / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
their own Renter insurance / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know / Yes No
Don’t know
Occupation / Employed
Students
Retirees
Unemployed / Social Assistance / Disability / Employed
Students
Retirees
Unemployed / Social Assistance / Disability / Employed
Students
Retirees
Unemployed / Social Assistance / Disability / Employed
Students
Retirees
Unemployed / Social Assistance / Disability / Employed
Students
Retirees
Unemployed / Social Assistance / Disability / Employed
Students
Retirees
Unemployed / Social Assistance / Disability
Unrelated people living together / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
ABOUT COVERAGES
Unpaid rents / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
Damage by tenants / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No

Date Coverage Required:Additional information or comments:

DECLARATION: Where (a) anApplicant for this contract gives false particulars to the prejudice of the insurer or knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or (b) the Insured contravenes a term of the contract or commits a fraud; or (c) the Insured willfully makes a false statement in respect of a claim, a claim will become invalid and the Insured's right to recovery is forfeited. TheApplicants have reviewed all parts and attachments of this application and acknowledge that all information is true and correct and understand that this application for insurance is based on the truth and completeness of this information. I have provided personal information in this document and otherwise and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker's or insurance company's policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf. Protection and Electronic Documents Act (PIPEDA)

______

Print name of proposed insuredSignature of Applicant & TitleDate

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Signature of BrokerDate

Tel.: 1-855-745-1010 - –