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Combined Home and Auto Insurance

Name:
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
Date of Birth:	(dd/mm/yyyy)
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 N/A
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