Home Insurance Quick Quote Form

(For residents of British Columbia only)

All estimates confidential, and for our company use only: no access given to outside mailing lists or agencies.

Name:
Address:
City:
Province:
Postal Code:
Phone #:
Fax #:
E-mail address:	(essential)

Are you a:

Tenant
Co-op Share Owner
Condominium Owner or
Home Owner?

General

(See our Home Inventory List for an accurate estimate of the value of your possessions)

Your Date of Birth:
Your Spouses Date of Birth:
If your spouse is common law, how many years have you continuously lived together?
Do you live with people unrelated to you?
What is the construction of your residence building?
Are there any commercial/business occupancies in your building?	Yes No
If yes, What types of commercial or business occupancies are there in your building?
How much coverage do you want on your personal belongings/home contents?
How much coverage do you want on your personal liability?	$1,000,000 $2,000,000
What is the value of business property that you keep at home?
Do you want "named perils" coverage or "all risk" coverage on your home contents?
Do you want earthquake coverage?	Yes No
Apartments or suites.... what floor is your unit on?
Apartments or suites.... how many stories are there in your building?
Apartments or suites.... how many apartments or suites are there in your building?
Are you a Block Watch member?	Yes No
Do you have a burglar alarm?	Yes No
Is your Alarm monitored?	Yes No
The name of the Monitoring Company:
Are Sprinklers installed in your residence unit?	YesNo
How many years have you been continuously insured to the present?
What deductible do you want?
In what year was your home built?

Floaters provide specific coverage on individual items. They are especially useful if you want a lower deductible, broader coverage, or you need more coverage than provided in the basic policy.

Do you need floaters for:

Camera/Video (Non-professional use):	Yes No	Value:
Camera/Video (Professional use):	Yes No	Value:
Stamp collections:	Yes No	Value:
Coin collections:	Yes No	Value:
Portable Computer Equipment:	Yes No	Value:
Non-portable Computer Equipment:	Yes No	Value:
Computer Software:	Yes No	Value:
Jewelry:	Yes No	Value:
Watches:	Yes No	Value:
Furs:	Yes No	Value:
Silverware:	Yes No	Value:
Bicycles: (Indicate value of each bike separately.)	Yes No	Value:
Fine Art: Is breakage coverage wanted on the fine arts?	Yes No Yes No	Value:
Sports Equipment: Description of Sports Equipment:	Yes No	Value:
Other: .....(Please describe)		Value:

Should you decide to be insured by our company, what date would you need your coverage to begin?
Have you ever been cancelled, declined, or refused renewal by an insurance company?	Yes No
Have you had any Losses (Claimed or Unclaimed) during the past 5 years?	Yes No

If yes, what were the Date(s), Amounts of Loss(es), Kind of Loss(es), and state if you filed a claim:
(Please List information on losses even if you did not file a claim or your claim was not settled)

Date of Loss	Amount of Loss	Kind of Loss	Did you File a Claim?
			YesNo
			YesNo
			YesNo
			YesNo
			YesNo
			YesNo

Homeowners (additional questions)

If your home was built more than 20 years ago, please specify which features have been renewed:

Electrical:	Partially renewed Fully renewed Year renewed:
Plumbing:	Partially renewed Fully renewed Year renewed:
Heating:	Partially renewed Fully renewed Year renewed:
Roofing:	Partially renewed Fully renewed Year renewed:

How much coverage do you want on the building?
How many mortgages are registered against your home?
Do you have any Roomers or Boarders?
Do you have any suites in your home rented out?

If you have any questions, comments, or additional information, please enter here::

Location

2425 Burrard Street
Vancouver, BC
V6J 3J3

Contact Us
Tel: (604) 736–7668
Fax: (604) 736–4375
Send us a message

Office Hours
Monday to Friday
9:00 am – 7:00 pm
Saturday
10:00 am – 4:00 pm