| * Name: |
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| * Email Address: |
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| * Address: |
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| * City: |
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| * Province: |
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| * Postal Code: |
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| * Phone Number: |
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| Fax Number: |
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* Do you own your own home,
own a condo unit or rent? |
Homeowner |
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Condo Owner |
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Renter |
| * Are you currently insured? |
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| Name of previous insurance company: |
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Estimated replacement value
of dwelling (homeowner only) |
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Estimated replacement value of
personal property (condo & renters only) |
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| * Policy deductible preferred: |
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| * Liability amount requested: |
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* Have you had any personal property
claimed in the past three years? |
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| Additional Comments: |
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Toll Free: 1-866-284-4748
