Quote Requests - Pacific Insurance

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Quote Requests

Home Insurance

Name:

Address:

City:

Province:

Postal Code:

(X1Y 2Z3)

Phone Number:

(123-456-7890)

Email Address:

(xxx@yyyy.zzz)

Have you ever had insurance cancelled or refused?

Yes No

Do you currently insure
your property?

Yes No

Number of years
prior insurance:

Expiry date with
present insurer:

(dd/mm/yyyy)

What is your date of birth?

(dd/mm/yyyy)

Property #1

Property #2

Property type:

Use:

Do you:

Year built:

If property over 20 years old, which of the following have been replaced?

	Furnace
	Roof
	Wiring
	Plumbing

	Furnace
	Roof
	Wiring
	Plumbing

Is property equipped
with an alarm?

If yes, is alarm

Are you within 300 m
of a hydrant?

Yes No

Are you within 13 km
of a firehall?

Yes No

Discount Information

I am mortgage-free

I am a non-smoker

Amount of coverage required

Building:

Contents:

Liability:

Deductible:

Recent claims

#1:

Type:
Date:	(mm/yyyy)
Location involved:

#2:

Type:
Date:	(mm/yyyy)
Location involved:

#3:

Type:
Date:	(mm/yyyy)
Location involved:

Comments: