Special Risk
Insurance Quote Sheet
 
Instructions: Please fill in the following information and a Qualified Johnston Meier Insurance Representative will contact you with your quote. 

Note: Quoted prices are only valid within the Province of British Columbia, Canada.

1.Type of Insurance 
2.
Building Limit
3.Deductible required
4.Limit of liability coverage required
5.Type of Structure
6.Construction of building
7.Year building constructed
8.Is there rental of any portion of the home
9.Type of heating
10.Wood Heat
11.Fire Protection
12.Mature Age Discount Applies
If Yes, please provide Date of Birth 
13.Alarm System
If yes,
14.Mortgage Free Discount Applies
15.Years Continuously Insured Claimsfree
16.Additional coverages requiredYes No 
     If yes, please give details:

17.Have you had any losses in the
last 3 years?
Yes No
     If so, give details & claims amount
     paid by the insurance company:
.
.
Additional information may be required in order to
verify rating. One of our qualified representatives will
contact you to confirm the information provided.
.
Contact Information
Name
Address
City
Postal Code
Email Address
Telephone #
Fax #