Tenant Request Form | Bicycle Broker

First Name *

Last Name *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Date of birth of owner *

Expiry of existing policy or desired effective date: *

List all unrelated Tenants - Indicate if Spouse or Common Law. Name + date of birth. ***Children of the primary policy holder are not required.

Use of the property *

What kind of building is this? *

How many years have you carried Tenant insurance in Canada? *

Does the property have an alarm system? *YesNo

Is it monitored? *YesNo

What year the building was built?

Do you know the building utility upgrade information? *YesNo

Heating Type

Heating - Month/Year Last Updated

Plumbing Type

Plumbing - Month/Year Last Updated

Wiring Amp

Electrical - Month/Year Last Updated

Roof Type

Roof - Month/Year Last Updated

What is the Primary heat source? *

Please Specify *

Limit of Liability requested? *

Deductible Requested *

Contents limit ($25 to $150k) **All of the personal belongings you store within the property and detached garages or storage lockers.

Would you like Sewer back up coverage? *YesNo

Would you like water protection coverage? *YesNo

Would you like Earthquake coverage? *YesNo

Would you like to add any bikes (over $1,000/each), jewellery (over $6,000/each), or artwork (over $15,000/each)? *YesNoFor Jewellery valued over $6,000/item you may be asked for an appraisal on the item that is no more than 12 months old.

Item Description

Item Description *

Purchase Price *

Date of Purchase

Have you had any claims in the last 5 years? *YesNo

List all claims paid and outstanding during the past five years. State whether net of deductibles. What was the deductible in each policy year?

If yes, please provide a description, including dollar amount paid or held in reserve? *

Has the applicant ever been declined or cancelled by an insurance company? *YesNo

Do you consent to a soft credit check? This does not impact your credit score. *YesNo

Does the building have a wood-burning fireplace or stove? *YesNo

Are there any farming operations or daycare or business run out of this location? *YesNo

Upload your existing policy documents

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Tenant Coverage Form

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