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    Your Name (required)

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    Date of Birth: (required)

    Occupation

    Do you have a mortgage or a line of credit?

    Do you have an alarm system?

    BurglarFireSprinkler

    If yes, is it monitored?
    YesNo

    How long have you lived at this location?

    Do you have a home-based business?

    Is this a non-smoking household?

    Current insurer and policy # with expiry date

    Current building insurance limit and/or contents limit (if a condo or tenant policy)

    How long have you had continuous property insurance?

    What deductible do you have?

    Have you had ANY claims or losses in the past 5 years?

    Is earthquake insurance required?
    YesNo

    Underwriting information required for your risk:

    Year Built (required)

    Is the house within 300 meters of a fire hydrant?
    YesNo

    Is the house within 8 kilometers of a firehall?
    YesNo

    How many floors?

    Is there a basement?

    If yes, is it finished?

    If yes, is it
    Above groundBelow ground1/2 and 1/2

    If no basement is it
    on a slabcrawlspace

    Is there a suite?

    If yes, is the suite rented?
    YesNo

    How many kitchens?

    Sq. footage of main floor and basement?

    What is exterior finish (wood, stucco, vinyl or other?)

    Hot water tank age?

    How many full bathrooms?

    How many 1/2 bathrooms?

    How many fireplaces?

    Gas?

    Wood?

    Decks sq. feet?

    type (wood, concrete or other?)

    Is there a garage or carport?

    If yes, is it attached, detached or built in and what size - 1 or 2 car?

    Do you have a swimming pool?

    If yes, is it concrete or vinyl?

    In-ground or above?

    What is the size of the pool?

    Do you have a hot tub?

    If yes what is the size?

    Roof age and type (asphalt, wood, metal, clay tile or other?)

    If replaced, what year?

    Electrical Age and type (copper, aluminum or knob and tube?)

    Are there breakers or fuses?

    Is it 60, 100 or 200 amp service?

    Type of heating - electric or gas furnace?

    If furnace, age?

    Do you have your furnace serviced annually?

    Plumbing age and type (copper, plastic or cast?)

    Is there a woodstove?

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    Contact Us

    Unit 211, Mission Hills Mall
    32530 Lougheed Highway
    Mission, BC V2V 1A5
    Telephone (604) 826-7141
    Facsimile (604) 826-1893
    Email: erin@kirbyinsurance.net
    Hours

    Monday – Friday 9:00 am – 7:00 pm
    Saturday 9:00 am – 6:00 pm
    Sunday 10:00 am – 5:00 pm
    Store Location