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
• Auto Insurance
• Home Insurance
• Combined Home and Auto
• Business Insurance
• Boat Insurance
• Farm Insurance
• Trucking Insurance
• Recreational Vehicle
• Travel Trailer Insurance
• Motorcycle Insurance
• Tenants Insurance