Buckler Insurance Service Ltd. - Combined Home and Auto Insurance

Many people believe the amount they paid for their home is the same as the replacement cost on their insurance policy. However, this is not the case.

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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:	HomeownerCondo OwnerRenter
Estimated replacement value of dwelling (homeowner only):
Estimated replacement value of personal property (condo & renters only):
Policy deductible preferred:
Liability amount requested:
Have you had any personal property claims in the past three years:	YesNo
Auto
Date of Birth:	Date and time
Marital status of principal driver:
Number of years licensed for principal driver:
Gender of additional drivers under 25 years of age:
Do driver(s) under 25 years of age have driver training certification:	YesNo
Do you use your vehicle for business:	YesNo
Do you use your vehicle to commute to and from work:	YesNo
VIN #:
Liability limit requested:
Coverage Preferred:
Deductible:
Additional vehicles to be quoted:	YesNo
Is there someone in our office who you have been working with or you would like to review your request:
Effective Date:	Date and time
Drivers License #:
What date did you obtain your G1:	Date and time
What date did you obtain your G2:	Date and time
What date did you obtain your G:	Date and time

Quotes