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Buckler Insurance Services
Personal
Automobile Insurance
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Condominium Insurance
Home Insurance
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Seasonal Residence Insurance
Tenants Insurance
Umbrella Liability Insurance
Yacht Insurance
Commercial
Commercial Fleet Insurance
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Auto Insurance
Name:
(Required)
Address:
(Required)
City:
Province:
Postal Code:
Phone Number:
(Required)
Email Address:
Date of Birth:
MM slash DD slash YYYY
Name of Principal Operator:
Number of child(ren) who are licensed drivers:
First Child
Name of child:
Date of Birth:
MM slash DD slash YYYY
Number of years licensed for driver:
Second Child
Name of child:
Date of Birth:
MM slash DD slash YYYY
Number of years licensed for driver:
Any at fault accidents in the past 6 years:
Yes
No
Any driving convictions in the past 3 years:
Yes
No
If yes, no. of claims & details:
If yes, no. of tickets & details:
Value of Rec. Vehicle
Number of CC's:
List Price New:
List Each Vehicle you wish to insure
First Vehicle
Make:
Model:
Serial number:
Second Vehicle
Make:
Model:
Serial number:
Third Vehicle
Make:
Model:
Serial number:
Liability limit requested:
$1,000,000
$2,000,000
$5,000,000
Coverage Preferred:
All perils
Collision
Comprehensive
Specified perils
Deductible:
$250
$500
$1000
Can we Quote on your Home & Auto:
Yes
No
If yes, when does it expire:
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