Total Insurance – Tenants Questionnaire

Applicant(s) Information

Row 1 Col 1 Start

Applicant #1

Applicant Name

Birthdate

Email

Phone/Cell

Row 1 Col 1 End

Row 1 Col 2 Start

Applicant #2

Applicant Name

Birthdate

Email

Phone/Cell

Row 1 Col 2 End

Mailing Address

Street Address Address Line 2 City Province Postal Code

Permanent Address (if different than above)

Street Address Address Line 2 City Province Postal Code

First Time Insured

Yes
No

Non-Smoker

Yes
No

Credit Score Consent

Yes
No

Have You Ever Been Refused/Denied or Cancelled for Insurance

Yes
No

Previous Company and Policy #

Previous Address (if less than 3 years)

Street Address Address Line 2 City Province Postal Code

Claims History

Years Claim Free

3 Years Claim Free
5 Years Claim Free
10 Years Claim Free

Prior Loss

Location

Street Address Address Line 2 City Province Postal Code

Loss Date

Cause of Loss

Payout

Yes
No

Amount

Coverage

Contents Limit Requested

Construction Type

Frame
Steel
Fire Resistive

Heating

Electric
Forced Air Gas
Wood Heat

Stories

Deductible

$500
$1000

Increased Liability

Yes
No

Sewer Backup

Yes
No

Initials

I/We authorize Total Insurance Agency Inc. to forward confirmation of coverage to my property manager

Yes
No