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| Home Quote |
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| Name: |
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| Date of Birth: |
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| Co-Applicant Name: |
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| Co-Applicant DOB: |
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| Address: |
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| City: |
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| Postal Code: |
(X1Y 2Z3) |
| Phone Number: |
(123-456-7890) |
| Email Address: |
(xxx@yyyy.zzz) |
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| Type of Policy: |
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| How many years have you carried property insurance insurance: |
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Amount of Insurance Required
(Building or Contents Limit): |
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| Current Liability Limit: |
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| Current Deductible: |
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| How far is your location from a fire hydrant? |
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| How far is your location from a fire station? |
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| Is everyone in your household a non-smoker? |
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| Do you have a monitored fire alarm? |
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| Do you have a monitored burglar alarm? |
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| Do you run a business from you home? |
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| How many mortgages are on your property? |
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| Year property was built? |
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| Type of Plumbing: |
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| Type of Wiring: |
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| Type of Heat: |
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| Age of Furnace: |
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| Age of Roof: |
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| Do you have a woodstove? |
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| How many home claims have you had in the past five years? |
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| Auto Quote |
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| Please list all drivers in the household below: |
| Driver 1 |
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| Name |
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| Birthdate: |
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| Year First Licensed: |
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| Sex: |
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| Marriage Status: |
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| Licence Class |
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| Number of driving convictions/tickets in the last 3 years: |
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| Has the above driver had any accidents or claims in the past 10 years? |
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| Claims Information: |
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| Claims |
Date (mm/yyyy) |
Driver involved |
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| #1: |
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| #2: |
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| #3: |
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Driver 2 |
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| Name |
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| Birthdate: |
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| Year First Licensed: |
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| Sex: |
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| Marriage Status: |
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| Licence Class |
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| Number of driving convictions/tickets in the last 3 years: |
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| Has the above driver had any accidents or claims in the past 10 years? |
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| Claims Information: |
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| Claims |
Date (mm/yyyy) |
Driver involved |
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| #1: |
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| #2: |
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| #3: |
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Driver 3 |
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| Name |
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| Birthdate: |
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| Year First Licensed: |
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| Sex: |
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| Marriage Status: |
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| Licence Class |
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| Number of driving convictions/tickets in the last 3 years: |
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| Has the above driver had any accidents or claims in the past 10 years? |
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| Claims Information: |
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| Claims |
Date (mm/yyyy) |
Driver involved |
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| #1: |
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| #2: |
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| #3: |
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Driver 4 |
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| Name |
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| Birthdate: |
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| Year First Licensed: |
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| Sex: |
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| Marriage Status: |
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| Licence Class |
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| Number of driving convictions/tickets in the last 3 years: |
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| Has the above driver had any accidents or claims in the past 10 years? |
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| Claims Information: |
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| Claims |
Date (mm/yyyy) |
Driver involved |
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| #1: |
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| #2: |
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| #3: |
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| Do driver(s) under 25 years of age have driver training certification? |
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| Please list all the vehicles on your policies: |
| Vehicle 1 |
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| Year: |
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| Make: |
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| Model: |
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| Km Driven to Work: |
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| Vehicle 2 |
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| Year: |
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| Make: |
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| Model: |
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| Km Driven to Work: |
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| Vehicle 3 |
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| Year: |
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| Make: |
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| Model: |
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| Km Driven to Work: |
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| Vehicle 4 |
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| Year: |
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| Make: |
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| Model: |
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| Km Driven to Work: |
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| Current Liability Limit: |
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| Current Collision Deductible: |
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| Current Comprehensive Deductible: |
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| Any licence suspensions
in past 6 years? |
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| Any company cancellations
in past 6 years? |
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| Any gaps of insurance
in past 6 years? |
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Disclaimer |
