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Marianne Cipollone, Insurance Broker
Cell:
(416)-994-0892
Office:
(905)-660-8278
Email:
marianne@oraclerms.com
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:
Security Code:
Enter security code:
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