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Combined Home and Auto
Name:
Address:
City:
Province:
Postal Code (X1Y 2Z3):
Phone Number (123-456-7890):
Email Address:
Date of Birth:
Date and time
Home
Do you own your own home or a condo unit:
Homeowner
Condo Owner
Renter
Estimated replacement value of dwelling (homeowner only):
Estimated replacement value of personal property (condo & renters only):
Policy deductible preferred:
$300
$500
$1,000
Liability amount requested:
$1,000,000
$2,000,000
Have you had any personal property claims in the past three years:
Yes
No
Auto
Age of principal driver:
Marital status of principal driver:
Married
Single
Number of years licensed for principal driver:
Gender of additional drivers under 25 years of age:
Male
Female
Do driver(s) under 25 years of age have driver training certification:
Yes
No
Any at fault accidents in the past 6 years:
Yes
No
Any driving convictions in the past 3 years:
Yes
No
Do you use your vehicle for business:
Yes
No
Do you use your vehicle to commute to and from work:
Yes
No
Year, make and model of vehicle:
Liability limit requested:
$200,000
$500,000
$1,000,000
$2,000,000
Coverage Preferred:
All perils
Collision
Comprehensive
Specified perils
Deductible:
$100
$250
$500
$1,000
Additional vehicles to be quoted:
Yes
No
Is there someone in our office who you have been working with or you would like to review your request:
Overview
Automobile Insurance
Property Insurance
Combined Home and Auto
Business Insurance
Boat Insurance
Farm Insurance
Recreational Vehicle
Travel Trailer Insurance
Term Life Insurance
Critical Illness Insurance
Disability Insurance
Mortgage Insurance
Key Person Insurance
Tenants Insurance
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