VB Insurance Brokers Limited

Request for Quotation
Residential - Homeowner Insurance


Offered ONLY to Residents of Alberta

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Important: Please be accurate in completing this form. Your quotation will be based on the information you give us today. If these facts change, your rate will be subject to adjustment.


Personal Information

   First Name:                
   Last Name:                 
   E-Mail:                    
   Date of Birth:              (mm/dd/yyyy)
   Address:                   
   City/Town:                 
   Province:                  
   Postal Code:               
   Home Telephone:            
   Business Telephone:        
   Fax Number:                
   Spouse's Name:             
   Spouse's Date of Birth:     (mm/dd/yyyy)
CURRENT POLICY INFORMATION 
     Insurance Company:       
     Policy Number:           
     Policy Expiry Date:        (mm/dd/yyyy)
     Amount of Insurance:    $

Property Description

   Is the dwelling within 8km (5 miles) of a firehall?      YesNo
   Is the dwelling within 300m (1000ft.) of a fire hydrant? YesNo
   Do you run a business from the premises?                 YesNo
   Number of families in dwelling:                       
   Year of Construction:                                  (yyyy)
      If built over 15 years ago, indicate the year the following
      were last upgraded:
                 Electrical:   (yyyy)     Plumbing:  (yyyy)
                 Roofing:      (yyyy)     Heating:   (yyyy)
   Number of Smoke Detectors:  Number of Deadbolts: 
   Is dwelling equipped with:
         Centrally monitored burglar alarm?                  YesNo
         Centrally monitored fire alarm?                     YesNo
   Does the dwelling have an oil tank?   
            Yes                   Age:  Years
             No  
   Do you have a pet? Yes   
                      No

   
   
   Area of MAIN Floor:          
   
          If Other, specify: 
   
          If Other, specify: 
   
          If Other, specify: 

   Number of Bathrooms:      (4 piece or more)
                             (3 piece)
                             (2 piece)
      If you have bathrooms with more than 4 pieces please provide details:
      (How many pieces?/ How many bathrooms?)
                            

   Number of Fireplaces:     (Inside chimney)
                             (Outside chimney)
Does the Dwelling include: 
      Garage?
         Yes       
                     
            Number of Cars: 
         No

      Finished Basement?
            Yes   Living Space:  
                     Rec. Room:    
            No

      Sunroom?
            Yes   Area:  
                    Number of Stories: 
                    Does the Sunroom have a Basement?  YesNo
            No

      Deck?
            Yes   Area:  
            No

      Porch (Ground area)?
         Porch #1   
                         
                         
            Area:    

         Porch #2   
                          
                          
            Area:    

      Inground Swimming Pool?
            Yes   Area:  
                           
                           If Other, specify: 
            No

      Above Ground Swimming Pool?
            Yes   Area:  
            No

      Finished Attic?                                        YesNo
      Central Air Conditioning?                              YesNo
      Wood Burning Stove?                                    YesNo
Select Specialty Rooms from the following list:
Den (not converted bedroom)
Family Room (in addition to a Living Room)
Formal Dining Room (not dining area, dinette or breakfast nook)
Large Foyer (over 70 sq. ft.)
Laundry Room (over 70 sq. ft.)
Library
Office
Recreation Room
Study
Sunroom
OtherHomeowner Insurance Specify:

Claims Information

Have you made ANY claims in the past five years?

   Yes  Date          Description of Claims         Amount of Loss
         
   No

Optional Coverages

Personal Articles

You may wish to insure the items mentioned below for amounts in excess of the existing policy limits. Please state the total value of these items you wish to insure seperately.
   Fine Art:      $
   Furs:          $
   Jewellery:     $
   Other:         $  Specify:

Secondary/Seasonal Dwelling

   Address:                   
   Country:                   
   Lot #:                     
   Postal Code:               
   Is the dwelling within 8km (5 miles) of a firehall?       YesNo
   Is the dwelling within 300m (1000 ft.) of a fire hydrant? YesNo
   Contents value:           $
   Building Value:           $
If over $100,000, please fill in an additional Residential Request for Quotation and complete the Homeowners sections.

Watercraft

Year:    (yyyy)                        Original Cost: $
Length:     Speed:     Horsepower:

Do you have an Auto Policy with us? 
            Yes  Policy number? 
            No

Please check that you have supplied all information requested.

Every question on each Request for Quotation is important. Please complete each section in full, so that all your applicable discounts can be determined.


Website URL:www.vbins/mcsnet.ab.ca
Last modified on August 26, 2000 by VB Insurance Brokers Ltd.