Fill out the Home Insurance form or download the printable PDF below:

Home Insurance PDF

    Client Details

    Client 1

    Client 2

    Client 3

    Client 4

    Previous Address (If resided at current residence for less than 3 years)

    Previous Insurance History

    *If Applicable

    Mortgage / Credit Consent

    House Details


    Dwelling Construction Type

    Fire Protection


    Primary Heat Type:

    Auxiliary Heat Type (if applicable):
    Wood-stoveWood InsertPellet Stove

    Oil Tank (if applicable)

    InsideOutsideIn groundAbove ground

    Single wallDouble wall




    Water Prevention Sump pump and/or Back flow valve

    Additional Questions

    Home Base Business: YesNo


    Please do not hesitate to reach out if you have any questions at all.

    The right products, great service, the best people

    Contact Us

    Cooper Location – Orchard Plaza

    Tel: 250-860-6064
    Fax: 250-860-6094

    Glen Park Location – Glen Park Village

    Tel: 250-862-9700
    Fax: 250-862-9742