Complete Insurance Services for peace of mind - Seafirst Insurance

CHBA COC APPLICATION

CLIENT INFORMATION

Name:
Mailing Address:
City:		Province:
Country:		Postal:
Phone:		Website:
Fax:		E-mail:

PROJECT INFORMATION

Project Name:		Project #	if applicable
Address:
City:
Province:		Postal Code:
Type of Project:	House Duplex Triplex Other
if Other Describe:

RISK INFORMATION

Project
Start Date of Foundation:
Completion Date:
Hard Cost:
Soft Cost:
Total Sum Insured:

Construction
Stories:		Area:	Ft 2 m 2

Walls	Siding	Floors	Roof	Foundation
Wood	Wood	Wood	Wood	Concrete
Non Combustible	Brick	Non Combustible	Asphalt	Other
Other	Other	Other	T & G
			Other

Fire Protection
Hydrants:	Unprotected	Within 300m	Over 300m
Fire hall:	No Fire hall	Within 8k	Over 8k
Security Guard:	None	24 hours	While Not Working Other

Exposures: Distance and type of building in feet.
Clear All Sides
Left of Insured	ft.
Right of Insured	ft.
Behind Insured	ft.

Loss Payees & Additional Insured's:
Name:

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