Combined Home and Car Insurance Name Address City Province Postal Code Phone Email Date of Birth Home Do you own your own home or a condo unit: HomeownerCondo OwnerRenter Estimated replacement value of dwelling (homeowner only): Estimated replacement value of personal property (condo & renters only): Policy deductible preferred: $1,000$500$300 Liability amount requested: $2,000,000$1,000,000 Have you had any personal property claims in the past three years: YesNo Auto Age of principal driver: Marital status of principal driver: MarriedSingle Number of years licensed for principal driver: Gender of additional drivers under 25 years of age: MaleFemale Do driver(s) under 25 years of age have driver training certification: YesNo Any at fault accidents in the past 6 years: YesNo Any driving convictions in the past 3 years: YesNo Do you use your vehicle for business: YesNo Do you use your vehicle to commute to and from work: YesNo Year, make and model of vehicle: Liability limit requested: $2,000,000$1,000,000$500,000$200,000 Liability limit requested: All perilsCollisionComprehensiveSpecified Perils Deductible: $1,000$500$100 Additional vehicles to be quoted: YesNo
