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Applicant Information

Your name:
Your e-mail:
Your Address:
Your Postal Code:
Day time phone number:
Date of upcoming renewal:
Occupation:
Date of Birth:
Are you currently insured with Cooke Insurance Group?
Yes  No  
To insure maximum discounts, are you or other primary operators a member of the following groups or associations?

Please specify other Group or Assosiation:
Please indicate other quotes your may require:
Property
Commercial Insurance
Recreational
Trailers
 Individual or Group Mortgage
Life Insurance
Individual or Group Health Insurance


Dwelling Information

Street address of dwelling:
City:
Province:
Postal Code:
In what year was your residence built?:
What is the Electric Ampage of your home? NOTE: If your ampage is 60, please contact a Charlie Cooke Insurance Broker to discuss your property
What type of dwelling is it?
Total Square Footage
Do you have commercial operations on the premises?
Yes    No
What is the primary method of heating in the residence?
If it is oil heating, what is the age of the tank?
Is the oil tank situated inside or outside?
What additional heating do you use to heat your residence?
If you burn wood for heat, approximately how many cords are burned a year?
Is the dwelling fire hydrant protected?
Yes    No
If yes, how close is a fire hydrant to your property?
How close is your property to the nearest fire hall?
Do you have any alarm systems in your property?
Yes    No
If yes, is the alarm system monitored for both fire and burglary?
Yes    No

Rating Information
Do you occupy the residence?
Yes    No
Do you have any tenants occupying the property?
Yes    No
What type of property insurance do you need?
Do you operate a home-based business from your property?
Yes    No
How many mortgages do you have on your residence?
Do you currently have a property insurance policy?
Yes    No
If no, what reason best describes why you are not presently insured?
Have you had a property insurance policy in the past 5 years?
Yes    No
If yes, how long have you had this property insurance policy without interruption?
How many property insurance claims have you had in the last 5 years?
If you've had property insurance claims, please describe the date and type of claim:
In the past 5 years, have you had a property insurance policy cancelled by an insurance company OR has an insurer ever refused to insure this residence?
Yes   No

Coverages
Type of Coverage:
Deductible:
Liability Coverage:
Do you have any special items that require special coverage consideration?


Dwelling %#% Information

Street address of dwelling:
City:
Province:
Postal Code:
In what year was your residence built?:
What is the Electric Ampage of your home? NOTE: If your ampage is 60, please contact a Charlie Cooke Insurance Broker to discuss your property
What type of dwelling is it?
Total Square Footage
Do you have commercial operations on the premises?
Yes    No
What is the primary method of heating in the residence?
If it is oil heating, what is the age of the tank?
Is the oil tank situated inside or outside?
What additional heating do you use to heat your residence?
If you burn wood for heat, approximately how many cords are burned a year?
Is the dwelling fire hydrant protected?
Yes    No
If yes, how close is a fire hydrant to your property?
How close is your property to the nearest fire hall?
Do you have any alarm systems in your property?
Yes    No
If yes, is the alarm system monitored for both fire and burglary?
Yes    No

Rating Information
Do you occupy the residence?
Yes    No
Do you have any tenants occupying the property?
Yes    No
What type of property insurance do you need?
Do you operate a home-based business from your property?
Yes    No
How many mortgages do you have on your residence?
Do you currently have a property insurance policy?
Yes    No
If no, what reason best describes why you are not presently insured?
Have you had a property insurance policy in the past 5 years?
Yes    No
If no, how long have you had this property insurance policy without interruption?
How many property insurance claims have you had in the last 5 years?
If you've had property insurance claims, please describe the date and claim:
In the past 5 years, have you had a property insurance policy cancelled by an insurance company OR has an insurer ever refused to insure this residence?
Yes   No

Coverages
Type of Coverage:
Deductible:
Liability Coverage:
Do you have any special items that require special coverage consideration?

        


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