Intake Forms - Elite Coverage

Insurance Intake Forms — British Columbia

Complete the intake that fits your needs. A licensed BC advisor reviews every submission and reaches out within one business day with tailored quotes.

Intake Forms Life Insurance

First Name

Last Name

Date of Birth

Gender

Phone/Mobile

City (BC)

Postal Code

Annual Income (CAD)

Height (cm)

Weight (kg)

Tobacco / cannabis use in last 12 months? *

Yes

Alcohol consumption

Pre-existing conditions (diabetes, heart, cancer, etc.)

Tobacco / cannabis use in last 12 months?

Yes

Hazardous hobbies (aviation, diving, racing)?

Yes

Policy Type

Coverage Amount

Primary Beneficiary (name & relation)

Number of Dependents

Existing life insurance in force

Yes

Primary purpose of coverage

Additional notes for the advisor

I consent to be contacted by a BC-licensed life insurance advisor regarding my application. My information is protected under PIPEDA and never sold.

Intake Forms Fleet Insurance

Company / Owner Name

Primary Contact

Phone

City (BC)

Postal Code

Industry

Current ICBC broker

Number of Vehicles

Primary Use

Operating Radius (km)

Vehicle Types

Typical Cargo

Average km per vehicle / year

Where are vehicles garaged?

Number of Drivers

Most common licence class

Minimum driving experience

Any at-fault claims or violations in last 3 years?

Yes

Liability Limit Required

Collision / Comprehensive needed?

Yes

Cargo Insurance needed?

Yes

Telematics / GPS installed?

Yes

Claims history (last 5 yrs)

I consent to a licensed commercial auto broker reviewing my fleet details and ICBC history to prepare quotes.

Intake Forms Mortgage Insurance

First Name

Last Name

Date of Birth

Phone

Property City (BC)

Property Postal Code

Property Type

Occupancy

Co-applicant on mortgage?

Yes

Mortgage Lender

Current Mortgage Balance (CAD)

Remaining Amortization (years)

Interest Rate (%)

Renewal / Maturity Date

Is this a new purchase / refinance?

Yes

Monthly Mortgage Payment (CAD)

Coverage Type

Coverage Amount

Term Length

Tobacco use in last 12 months?

Yes

Pre-existing medical conditions

Existing lender creditor insurance?

Yes

I consent to be contacted by a BC-licensed advisor regarding mortgage life and disability insurance options. My information is PIPEDA-protected.

Intake Forms Commercial Business

Legal Business Name

Operating Name (DBA)

Structure

Industry

NAICS Code (if known)

Years in Business

URL

Primary Business Address

Profession / Industry

Professional Licence / Designation

City (BC)

Postal Code

City

Zip Code

Primary Contact

Title / Role

Phone/Mobile

Number of Employees

Annual Payroll (CAD)

Annual Revenue (CAD)

Number of Locations

Own the building?

Yes

Lease requires specific coverages?

Yes

Building Replacement Value (if owned

Contents / Inventory Value

Computers / Electronics Value

Stock / Inventory Value

Tenant Improvements Value

Property kept off-premises?

Yes

Monitored alarm / sprinklers?

Yes

Encrypted submission. Compliant with BC FSRA & FCAC privacy standards.

Your personal information is collected, used, and disclosed in accordance with Canada’s Personal Information Protection and Electronic Documents Act (PIPEDA) and British Columbia’s Personal Information Protection Act (PIPA BC). Information collected on this form is used solely to prepare your insurance quote and contact you about coverage options. It is stored on encrypted Canadian servers, never sold or shared with third parties for marketing, and you may request access, correction, or deletion of your data at any time.

Data Controller: Neha Mehta — Licensed BC Insurance Advisor · Phone: 778-683-1200. Submitting this form does not create a binding insurance contract. Coverage is subject to carrier underwriting approval.

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Insurance Intake Forms — British Columbia

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