MONTHLY PAYMENT PLAN

Authorization form for commercial insurance policies

Complete this form, attach a void cheque, and send it to your broker to sign up for our monthly payment plan. Talk to your broker if you
prefer to pay in one or three instalments.

Broker number

First policy number Second policy number

Payor’s name

Address City

Province Postal code

Name of financial institution (Canadian only)

Address of financial institution branch

Financial institution number Transit number Account number

3 digit Bank number 5 digit branch trans- Account number
it
Specify your scheduled withdrawal date, from 1, 8, 15, 20, 22, or 28:
Day of the month for withdrawals

I (account holder) accept the terms and conditions listed below, and authorize Economical Insurance to debit/credit funds from/to the bank account
stated above for the payment of the insurance policy/policies noted.

Date Signature of bank account holder Signature of second bank account

holder if joint account
[ Date ] [ Signature ]

Your signature confirms:
• You give permission to the noted financial institution (or any substitute that you
identify) to debit your account for withdrawals made by Economical Insurance.
• You understand the terms and conditions of the Scheduled Payments Plan.
• You understand your withdrawal amounts may vary if changes occur to your
policy premium.
• You understand this authorization is continuous and will automatically apply to the
renewal terms, unless Economical Insurance is instructed differently.
• You understand this authorization may be cancelled by written request provided full
payment of the balance has been received. Notification must be sent to your broker
a minimum of 14 days prior to the cancellation date of the agreement.
• You agree to have the necessary funds available to cover the amount of the
payments due.
• You understand if your financial institution indicates non-sufficient funds (NSF),
Economical Insurance may attempt another account withdrawal (a representment).
• You understand if your financial institution indicates NSF on the represented
withdrawal, an NSF fee may be charged to your account in addition to your monthly
payment. A notification will be mailed to you advising of a special withdrawal to
obtain your insurance premium and another for the NSF fee withdrawal. A payment
returned as NSF may result in the cancellation of your policy.
• You may dispute any account discrepancies by providing a signed declaration to
your financial institution within 90 days of the withdrawal date.
• You understand Economical Insurance will adjust your banking information if
notification of change is received directly from your financial institution.
• You understand Economical Insurance cannot be held liable for the service charges
levied by your financial institution.
• You certify all account information and signatures provided are accurate and agree
to inform Economical Insurance of any changes in the account information at least 14
days prior to the next due date, and that this agreement continues in respect of any
new account to be used for the withdrawals.
• You agree to the disclosure of any personal information, which may be contained in
this agreement, to your financial institution.

Economical Insurance includes the following companies: Economical Mutual Insurance Company, Family Insurance Solutions Inc., Sonnet Insurance Company, Petline Insurance Company. ©2018 Economical Insurance. All Economical intellectual property
belongs to Economical Mutual Insurance Company. All other intellectual property is the property of their respective owners. 6498-072018
 CANCELLATION AGREEMENT

NAMED INSURED: Manuel Martinez

By your signature below, you agree that liability under Policy Number ADH2405263
shall cease at 12:01am standard time.

REQUESTED CANCELLATION DATE: [ Date ]

Re: Home Insurance Cancellation

NAME OF INSURANCE COMPANY Travelers Insurance

DATED AT:

[ Date ]
THIS: ________________________________
(DATE)

ALL NAMED INSUREDS MUST SIGN.

[ Signature ]
YOUR SIGNATURE(S): X________________________________

X________________________________

PLEASE SIGN AND RETURN VIA

FAX 905-471-3894 or EMAIL
 BILLING METHOD
HABITATIONAL INSURANCE APPLICATION COMPANY BILL

INSURANCE QUOTE BINDER POLICY

COMPANY NUMBER NUMBER
X NEW
Definity Insurance Company BIND15445 BIND15445
RENEWAL

1. APPLICANT'S FULL NAME AND POSTAL ADDRESS 2. BROKER'S NAME AND POSTAL ADDRESS

NAME MARTINEZ, MANUEL NAME Cornell Insurance Brokers Ltd.

ADDRESS 1111 Elm Ave ADDRESS 275 Renfrew Dr.
Suite 200

CITY, POSTAL CITY,

Windsor, ON N9A5H8 Markham, ON POSTAL L3R 0C8
PROV CODE PROV CODE
CONTACT CONTACT
NAME NAME Rick
HOME (519) 256-0766 CELL (519) 996-0857 BUSINESS (905) 471-3868 CELL

BUSINESS ( ) - FAX ( ) - EMAIL

marinayfam6@hotmail.com BROKER BROKER SUB-

EMAIL 4782
CONTRACT NO. CONTRACT NO.
BROKER COMPANY
WEBSITE
CLIENT ID
MARM26 CLIENT ID
PREFERRED GROUP GROUP ID
LANGUAGE X ENGLISH FRENCH NAME

3. POLICY PERIOD
EFFECTIVE DATE YYYY/MM/DD TIME EXPIRY DATE YYYY/MM/DD
ALL TIMES ARE LOCAL TIMES AT THE
2023 12 29 12:01 A.M. X P.M. 2024 12 29 AT 12:01 A.M. APPLICANT'S ADDRESS SHOWN ABOVE.

4. APPLICANT DATA
APPLICANT 1 APPLICANT 2
NAME MARTINEZ, MANUEL NAME
YEARS CONTINUOUSLY YEARS CONTINUOUSLY
OCCUPATION
EMPLOYED 45 OCCUPATION EMPLOYED
DATE OF BIRTH YYYYMMDD
1958 3 8 DATE OF BIRTH YYYYMMDD

CLAIMS HISTORY
5. LOSS HISTORY REPORT DATE
HAVE THERE BEEN ANY LOSSES OR CLAIMS BY THE APPLICANT IN THE PAST 5 YEARS? YES X NO IF YES, COMPLETE THE TABLE BELOW.

DATE OF LOSS AMOUNT

YYYYMMDD LOC. # CAUSE OF LOSS STATUS PAID INSURANCE COMPANY POLICY NUMBER

DOES THE APPLICANT HAVE ANY KNOWLEDGE OR INFORMATION OF ANY FACT, CIRCUMSTANCE, OR SITUATION WHICH IF YES, PROVIDE DETAILS
YES NO
COULD REASONABLY GIVE RISE TO A CLAIM WHICH WOULD FALL WITHIN THE SCOPE OF THE PROPOSED INSURANCE? IN REMARKS SECTION.

CONTINUOUSLY
6. POLICY HISTORY INSURED SINCE
2015 12 29 FIRST TIME INSURED, NO PRIOR HABITATIONAL INSURANCE

EFFECTIVE DATE END DATE IF TERMINATED BY

INSURANCE COMPANY POLICY NUMBER YYYYMMDD YYYYMMDD REASON FOR ENDING INSURER, REASON

Travelers ADH 2021 12 29 2023 12 29

IN THE PAST FIVE YEARS, HAS ANY INSURANCE COMPANY DECLINED, CANCELLED, REFUSED OR
INDICATED AN INTENT NOT TO RENEW ANY HABITATIONAL INSURANCE POLICY? YES X NO IF YES, PROVIDE DETAILS IN REMARKS SECTION.

7. CROSS REFERENCE INFORMATION

LIST OTHER POLICIES WITH THIS INSURANCE COMPANY
LINE OF POLICY LINE OF POLICY
BUSINESS NUMBER BUSINESS NUMBER
LINE OF POLICY LINE OF POLICY
BUSINESS NUMBER BUSINESS NUMBER

CSIO - Habitational Insurance Application CA2001e 201810 Page 1 © 2018, Centre for Study of Insurance Operations. All rights reserved.
 PREMIUM TABLE
HABITATIONAL INSURANCE APPLICATION TOWN ID CODE
UNDERWRITING INFORMATION LOC NO. 1 NO. OF ATTACHMENTS

8. RISK ADDRESS X SAME AS POSTAL ADDRESS

ADDRESS CITY, POSTAL
1111 ELM AVE PROV
WINDSOR ON CODE N9A 5H8
9. RATING INFORMATION
1055 X
YEAR NO. OF NO. OF # OF TOTAL LIVING AREA sq ft
BUILT 1925 STORY'S (2.0) FAMILIES 1 UNITS 1 (excluding basement) ACCESS TYPE SMOKERS? N
m 2
REPLACEMENT COST DATE EVALUATION DATE OF BIRTH OF YYYYMMDD RELATIONSHIP TO
EVALUATOR PRODUCT Other COMPLETED 2023 11 28
YYYYMMDD ELDEST OCCUPANT APPLICANT Insured

OCCUPANCY TYPE Primary Residence AUXILIARY HEATING TYPE MAIN WATER VALVE SHUT OFF TYPEUnknown

APPARATUS None NO. OF MAIN WATER VALVE SHUT OFF SENSORS

STRUCTURE TYPE Detached
FUEL SEWER BACKUP QUESTIONNAIRE ATTACHED
FOUNDATION TYPE Basement
LOCATION
FINISHED BASEMENT 100 % FIRE PROTECTION

EXTERIOR WALL Brick Veneer

PROFESSIONALLY INSTALLED? YES NO DISTANCE TO HYDRANT within 150 metres
FRAMING TYPE
APPROVED BY ULC, CSA, OR WH? YES NO HYDRANT TYPE
EXTERIOR WALL Vinyl
FINISH TYPE DISTANCE TO RESPONDING
NO. OF FACE CORDS PER YEAR FIRE HALL 2 Kilometres
INTERIOR WALL CONSTRUCTION TYPE
SOLID FUEL HEATING QUESTIONNAIRE ATTACHED FIRE HALL
% % Windsor - F.S. #4
NAME
RADIANT HEATING AREA sq ft m2
%
MAKE YEAR SECURITY SYSTEM
INTERIOR WALL HEIGHT
FIRE
None
OIL TANK YEAR INSIDE IN GROUND
% % %
OUTSIDE ABOVE GROUND BURGLARY None
INTERIOR FLOOR FINISH TYPE FUEL TANK QUESTIONNAIRE ATTACHED SMOKE DETECTORS None
% %
SMOKE DETECTOR TYPE
% PLUMBING TYPE

COPPER % GALVANIZED % NO. OF DETECTORS 3

CEILING CONSTRUCTION TYPE IF ANY OF THE ABOVE ARE MONITORED, MONITORED BY
ABS % PVC %
% %
PEX % POLY-B %
%

LEAD % OTHER % ALARM CERTIFICATE ATTACHED

UPGRADES FULL(YY) PARTIAL(YY) PREMISES ACCESS

PLASTIC % SECURITY TYPE
ROOF 2015 WATER HEATER TYPE
HOME SPRINKLERED? YES NO
ELECTRICAL 2005 APPARATUS Storage Tank
BATHROOMS NO. OF FULL
1 NO. OF HALF
1
HEATING 2000 WATER HEATER YEAR 2014
PLUMBING 2006 FUEL Natural Gas KITCHENS NO. OF 1
KITCHEN #1 QUALITY
ROOF COVERING TYPE Asphalt Shingles PROFESSIONALLY INSTALLED? X YES NO

KITCHEN #2 QUALITY
ELECTRICAL WIRING TYPE Copper APPROVED BY ULC, CSA, OR WH? X YES NO

ELECTRICAL PANEL TYPE Breakers GARAGE / CARPORT NO. OF CARS

PRIMARY WATER MITIGATION TYPE
A None
SERVICE 100 SUMP PUMP TYPE GARAGE TYPE

PRIMARY HEATING TYPE AUXILIARY POWER

SWIMMING POOL YEAR
APPARATUS Furnace (Central) BACK UP VALVE
POOL FENCED? YES NO
FUEL Natural Gas
AUXILIARY WATER MITIGATION TYPE
LOCATION Basement
SUMP PUMP TYPE
PROFESSIONALLY INSTALLED? X YES NO
AUXILIARY POWER
APPROVED BY ULC, CSA, OR WH? X YES NO BACK UP VALVE

CSIO - Habitational Insurance Application CA2001e 201810 Page 2 © 2018 , Centre for Study of Insurance Operations. All rights reserved.
 HABITATIONAL INSURANCE APPLICATION
UNDERWRITING INFORMATION LOC NO. 1

DETACHED OUTBUILDINGS/STRUCTURES (Additional limits may be required on any heated outbuildings)

NO. YEAR STRUCTURE TYPE EXTERIOR WALL FRAMING TYPE HEATING APPARATUS TYPE FUEL TYPE TOTAL AREA VALUE
Sq ft
m2
Sq ft
m2
Sq ft
m2

10. MORTGAGEE / LOSS PAYEE(S)

NAME NATURE OF
1 INTEREST
CITY, POSTAL/
ADDRESS PROV/STATE ZIP CODE
NATURE OF
2 NAME INTEREST
CITY, POSTAL/
ADDRESS PROV/STATE ZIP CODE

NATURE OF
NAME
3 INTEREST
ADDRESS CITY, POSTAL/
PROV/STATE ZIP CODE

11. ATTACHMENTS
DATE COMPLETED DATE COMPLETED
ATTACHMENTS DESCRIPTION YYYYMMDD ATTACHMENTS DESCRIPTION YYYYMMDD

OCCUPANCY DATE
12. ADDRESS HISTORY FOR THIS LOCATION 1925 1 1 IF OCCUPANCY DATE IS LESS THAN 3 YEARS, PROVIDE PREVIOUS ADDRESSES BELOW.

DATE MOVED IN DATE MOVED OUT

NO. ADDRESS CITY PROV POSTAL CODE YYYYMMDD YYYYMMDD

1
2
3

13. LIABILITY EXPOSURES

All YES answers may require liability extension coverage or remarks explaining coverage declined.

1. DO YOU OWN / RENT MORE THAN ONE LOCATION? YES X NO 12. NUMBER OF FULL TIME RESIDENCE EMPLOYEES? 0
2. NUMBER OF WEEKS LOCATION RENTED TO OTHERS? 0 13. IS THERE A CO-OCCUPANT THAT REQUIRES COVERAGE? YES X NO

3. NUMBER OF ROOMS RENTED TO OTHERS? 0 CO-OCCUPANT NAME

4. DAYCARE OPERATION - NUMBER OF CHILDREN 0 14. IS THERE ANY KIND OF BUSINESS OPERATION? YES NO

5. DO YOU OWN A TRAMPOLINE? YES X NO IF YES, DESCRIBE BUSINESS

6. DO YOU HAVE A GARDEN TRACTOR? YES X NO

15. NUMBER OF DOGS IN THE HOUSEHOLD 0
YES X NO
7. DO YOU HAVE A GOLF CART? BREED(S) OF DOGS

8. NUMBER OF SADDLE / DRAFT ANIMALS? 0

16. TOTAL PROPERTY AREA (if greater than 1 acre) 0.0 acres

9. DO YOU OWN ANY UNLICENSED RECREATIONAL VEHICLES? YES X NO

17. NUMBER OF CANNABIS PLANTS GROWN ON PREMISES? 0
10. RENEWABLE ENERGY INSTALLATION ON PREMISES? YES X NO

X 18. OTHER EXPOSURES

11. DO YOU OWN ANY WATERCRAFT? YES NO

CSIO - Habitational Insurance Application CA2001e 201810 Page 3 © 2018, Centre for Study of Insurance Operations. All rights reserved.
 HABITATIONAL INSURANCE APPLICATION
COVERAGES AND LIABILITY EXTENSIONS LOC NO.1
14. COVERAGES
COVERAGE FORM TYPE 05 - Comprehensive Homeowners Form RATING PLAN Standard
REQUESTED/ AMOUNT OF DEDUCTIBLE TYPE OF ESTIMATED
COVERAGE DESCRIPTION DECLINED INSURANCE DEDUCTIBLE TYPE 1 2 3 4 5 PREMIUM

DWELLING BUILDING REQUESTED $326,983 2000 FL $899

DETACHED PRIVATE STRUCTURES REQUESTED FL
PERSONAL PROPERTY REQUESTED 2500 FL RC
ADDITIONAL LIVING EXPENSES REQUESTED FL
LEGAL LIABILITY REQUESTED $1,000,000 FL $25
VOLUNTARY MEDICAL PAYMENTS REQUESTED $5,000 FL
VOLUNTARY PROPERTY DAMAGE REQUESTED $1,000 FL
SEWER BACK-UP REQUESTED $326,983 FL $250
SINGLE LIMIT REQUESTED

GUARANTEED REPLACEMENT COST-BUILDING REQUESTED FL

REPLACEMENT COST ON CONTENTS
UNIT OWNERS BUILDING ALL RISK
IMPROVEMENTS AND BETTERMENTS NAMED PERILS
ALL RISK
LOSS ASSESSMENT NAMED PERILS
CONDOMINIUM CONTINGENT LEGAL LIABILITY
CONDOMINIUM ADDITIONAL PROTECTION ENDORSEMENT
IDENTITY THEFT REQUESTED FL
PERIL ADJUSTMENT - HAIL REQUESTED FL
OVERLAND WATER (FLOOD & REQUESTED $326,983 FL $13

EARTHQUAKE
POST-EARTHQUAKE DAMAGE

ESTIMATED PREMIUM FOR THIS SECTION $ 1,187

15. LIABILITY EXTENSIONS AND EXCLUSIONS
REQUESTED/ AMOUNT OF DEDUCTIBLE TYPE OF ESTIMATED
LIABILITY COVERAGE DESCRIPTION DECLINED DEDUCTIBLE TYPE
INSURANCE 1 2 3 4 5 PREMIUM

ESTIMATED PREMIUM FOR THIS SECTION $

16. DISCOUNTS AND SURCHARGES DISCOUNTS AND SURCHARGES continued
APPLIED TO EST. DISCOUNT APPLIED TO EST. DISCOUNT
PREMIUM PREMIUM
DISCOUNT/SURCHARGE DESCRIPTION % SURCHARGE DISCOUNT/SURCHARGE DESCRIPTION % Y/N SURCHARGE
Y/N
DISCOUNT - NO-CLAIMS
DISCOUNT - MORTGAGE FREE

ESTIMATED PREMIUM FOR THIS SECTION $

TOTAL ESTIMATED PREMIUM FOR THIS PAGE $ $1,187
CSIO - Habitational Insurance Application CA2001e 201810 Page 4 © 2018, Centre for Study of Insurance Operations. All rights reserved.
 HABITATIONAL INSURANCE APPLICATION
17. PREMIUM INFORMATION
TYPE OF PAYMENT PLAN ESTIMATED POLICY PREMIUM PROVINCIAL SALES TAX (if applicable) ADDITIONAL CHARGES % / $ TOTAL ESTIMATED COST

Monthly $1,187.00 $94.96 $1,281.96

AMOUNT PAID WITH APPLICATION AMOUNT STILL DUE NO. OF REMAINING NSTALMENTS AMOUNT OF EACH INSTALMENT INSTALMENT DUE DATE
$106.83 $1,175.13 11 $106.83

18. REMARKS

The producer is Richard Armstrong

CSIO - Habitational Insurance Application CA2001e 201810 Page 5 © 2018, Centre for Study of Insurance Operations. All rights reserved.
 HABITATIONAL INSURANCE APPLICATION
19. FULL DISCLOSURE
I, the Applicant, and the Insured if the Insurer has requested information from it, have reviewed all parts of and attachments to this application and declare that all of the
information is true and correct even if the information has been entered or suggested by the representative of the Insurer or by the insurance broker. I understand that
acceptance of this application for insurance is based on the truth and completeness of this information, and that:
For all provinces and territories except Quebec: If I falsely describe the For Quebec: I am bound to represent all the facts known to me which are likely to
property to the prejudice of the Insurer, or misrepresent or fraudulently omit to materially influence an insurer in the setting of the premium, the appraisal of the
communicate any circumstance that is material to be made known to the Insurer risk or the decision to cover it. The same applies to the Insured if the Insurer
in order to enable it to judge of the risk to be undertaken, the contract may be requires it. Any misrepresentation or concealment of relevant facts by me or the
void in whole or as to any property in relation to which the misrepresentation or Insured nullifies the contract, even in respect of losses not connected with the risk
omission is material. so misrepresented or concealed.
For all provinces and territories: Any fraud or wilfully false statement in a statutory declaration in relation to any of the particulars required by applicable conditions,
statutory or otherwise, to be specified in relation to a claim, vitiates the claim of the person making the declaration.

20. PERSONAL INFORMATION CONSENT

For all provinces and territories except Newfoundland and Labrador:

I am providing personal information of individuals in this form to apply for insurance. The personal information collected will be used for the purpose of
this application or any renewal or change in coverage. I consent and authorize my broker, agent or insurer to the following:
i) To collect, use and disclose personal information on this form to, from and between insurers and other appropriate parties, subject to my broker's,
agent's, and the insurer's policy regarding personal information. Such personal information will include policy history, loss history and rating
information.
ii) That these collections, uses and disclosures are for the purposes necessary to communicate with me and the listed applicants, assess, manage, and
underwrite risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settle claims, analyze
business results, detect and prevent fraud, as permitted by law.
iii) To collect only my personal credit information including my credit score from consumer reporting agencies, as permitted
by law for the purposes identified above. I understand that my consent for the use of credit information remains valid until
withdrawn by me in writing. By withdrawing or failing to provide my consent to the use of credit information, I understand
that I may not benefit from the best rates available to me.
I declare that all individuals whose personal information is contained in this form have authorized me to consent to i) and ii) above on their behalf.
If any other individuals wish to provide their consent with respect to the use of their credit information, they may provide their consent by also signing
below.
I may obtain a copy of or ask questions about my broker's, agent's or insurer's personal information policies by contacting their respective privacy
officers.

For Newfoundland and Labrador:

I am providing personal information of individuals in this form to apply for insurance.. The personal information collected will be used for the purpose of
this application or any renewal or change in coverage. I consent and authorize my broker, agent or insurer to the following:
i) To collect, use and disclose personal information on this form to, from and between insurers and other appropriate parties, subject to my broker's,
agent's, and the insurer's policy regarding personal information. Such personal information will include policy history, loss history and rating
information;
ii) That these collections, uses and disclosures are for the purposes necessary to communicate with me and the listed applicants, assess, manage, and
underwrite risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settle claims, analyze
business results, detect and prevent fraud, as permitted by law.
iii) To collect only my personal credit information including my credit score from consumer reporting agencies, as permitted
by law for the purpose of determining eligibility and conditions for a premium payment plan. I understand that my consent
for the use of credit information remains valid until withdrawn by me in writing.
I declare that all individuals whose personal information is contained in this form have authorized me to consent to i) and ii) above on their behalf.
I may obtain a copy of or ask questions about my broker's, agent's or insurer's personal information policies by contacting their respective privacy officers.

Les Parties ont convenu que cette proposition et les documents connexes solent rédigés en anglais.
The Parties have specifically agreed that this application and any attachments to this application be drawn in the English language.
MARM26
APPLICANT'S DATE YYYYMMDD APPLICANT'S DATE YYYYMMDD
SIGNATURE SIGNATURE

X [ Signature ] [ Date ] X
21. BROKER QUESTIONNAIRE
IS THIS BUSINESS NEW TO YOUR OFFICE? YES X NO SINCE WHAT DATE HAVE YOU KNOWN THE APPLICANT? 2017 9 12 HAVE YOU BOUND THIS RISK? X YES NO

ARE THERE SPECIAL CIRCUMSTANCES REGARDING THIS APPLICATION WHICH THE COMPANY SHOULD KNOW? YES X NO IF YES, PROVIDE DETAILS IN REMARKS

HAVE YOU SEEN THE PRIMARY LOCATION? YES NO IF YES, WHEN YYYYMMDD CONDITION OF PROPERTY GOOD FAIR POOR

BROKER'S NAME BROKER'S

(Please print) SIGNATURE

CSIO - Habitational Insurance Application CA2001e 201810 Page 6 © 2018, Centre for Study of Insurance Operations. All rights reserved.