Homeowners, Condominium & Tenant Quote Application





PART 1: Applicant / Contact Information

(* denotes required fields)

Name of Insured #1*:

Date of Birth*:

Name of Insured #2:

Date of Birth:

Mailing Address*:

Risk Address*:

Phone*:

Email*:

How did you hear about us?


PART 2: Policy Information

Policy Type
Homeowners  Yes No
Condominium  Yes No
Tenants  Yes No

Dwelling Value (home owners only):

Content Value (condo/tenants only):

Policy Deductible:

Liability Limit:

Scheduled Items:

Earthquake:
 Yes No

Previous Insurance Company:

Policy Number:

Year Insured with this Company:

Total Number of consecutive years insured with any company:

Have you ever been cancelled, refused or declined insurance in the past 5 years:

How long have you lived at this address:


PART 3: Building Information

Year Built:

Heating Type:

Number of Stories:

Number of units in building:

Number of Unrelated people in unit/building:

Total living area in square footage:

Protection Grade:
Within 300 meters of a hydrant and 8km of a fire hall  Yes No
Within 8km of a fire hall, hydrant beyond 300 meters  Yes No
Unprotected  Yes No


PART 4: Additional Discounts and Surcharges

Years Claims Free:

Monitored Alarm for Burglar:
 Yes No

Monitored Alarm for Fire:
 Yes No

Local Alarm:
 Yes No

24-hour Guard:
 Yes No

Wood Heat:
 Primary Secondary None

How many mortgages?:

Oil Tank (including above, below or not active):
 Yes No

Fire Resistive Building:
 Yes No

Sprinklers:
 Yes No

Block Watch:
 Yes No

Home Business:
 Yes No

Soft Credit Check:
 Yes No

Tankless Water Tank:
 Yes No

Non-smoker:
 Yes No

Co-op:
 Yes No

Claims History:

For Home owners, if home is over 25 years old we require updates of:
Roof (type and year updated)

Electrical (wiring type, amperage, year updated:

Heating (year updated):

Plumbing (type and year updated):

Hot Water Tank (age)

The above information is correct to the best of my knowledge
 I Confirm

Download Quote as PDF

Please click on icon to download form.
If you would prefer, download this PDF file, print and fill out quote details.
Fax or email to Chambers Olson Ltd. when you are ready to submit: 604-734-7644 or info@chambersolsonltd.com.

Questions?

If you have any questions please feel free to call us at 604-734-2288 or email info@chambersolsonltd.com