RV and Mobilehome Quote Form

BrokerForce Insurance Inc.
200 Consumers Rd. Suite 608
Toronto, Ontario M2J 4R4

Toll free:
800.263.9870
GTA:
416.494.2696
Fax:
416.494.7130
This form applies to:
Holiday Trailer, Park Model, R.V., Motor Home

Name:
 Last: First:
Address:
City:
Province: Postal Code:

Phone 1:
Phone 2:
Fax:
Email:

Desired effective date:
(Month ##, ####)
Legal Address:
(location of unit)
City:
Province: Postal Code:

Cottage
Phone:
Year: Manufacturer:
Model: Size (L x W):
Serial Number: Value:

Occupancy:
 Owner Occupied Tenant
  Summer/Seasonal Rented to Others
Protection:
 Protected (fire hydrant within 300m)
  Semi-protected (Firehall within 8km) Name:
Unprotectetd

Heating
  
Last Updated: Full: Partial:
Type:
Fuel:
Wood Heat: Cords/Yr: Bush: Face:

Wiring
  
Last Updated: Full: Partial:
Amps: 60 100 200 Breakers: or Fuses:
Type: Copper: Aluminum: Knob & Tube:

Roof
  
Last Updated: Full: Partial:
Material: Shingles: Tar & Gravel: Metal: Clay Tile: WoodShake:
  Other:

Plumbing
  
Last Updated: Full: Partial:
Pipes: Copper: Plastic: Galvanized: