Life Insurance Quote | Capital Insurance Brokers Edmonton

Assigned broker*
Part 1: Coverage
How did you hear about our company?
Who referred you to our company
We'll make sure to enter the person who referred you into our regular draws for gift certificates and other prizes!
What amount of insurance coverage do you need?*
What type of coverage do you need?*
Part 2: Personal Details for Person 1
Name of Person 1*
First Last
Date of Birth (MM/DD/YY)*
Gender*
- Male
- Female
Have you smoked or used tobacco in the past 12 months?*
- Yes
- No
Part 2b: Personal Details for Person 2
Name of Person 2
First Last
Date of birth for Person 2 (MM/DD/YY)
Gender
- Male
- Female
Have you smoked or used tobacco in the past 12 months?
- Yes
- No

Part 3: Contact Information
* IMPORTANT: This section must be fully and accurately completed in order for our licensed Alberta insurance brokers to provide you with an insurance quote. We will not sell your information to any third parties.
Address*
Street Address Address Line 2 City Province Postal Code
Home/cell phone number*
Business/work phone number
Email*
When would be the best time for a broker to contact you with your insurance quotes?*
- Anytime, as soon as possible
- Morning (9:00 am to 11:59 am)
- Afternoon (12:00 pm to 4:30 pm)
By clicking "I agree", I understand that the information from this form will be reviewed by a broker in order to provide an accurate quote. I also understand that Capital Insurance Brokers or an agent of Capital Insurance Brokers may contact me via phone or email to provide quotes or to obtain additional information needed to provide quotes.*
- I agree

Part 1: Coverage