Crossfield Agencies
Crossfield Agencies

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NAME
PHONE
EMAIL
INTERESTED IN

Address
Birthdate
Marital Status
Number of years licensed
Number of continuous years insured
Year of Vehicle
Make of Vehicle
Model of vehicle
Use  pleasure work commute commercial use
Number of km per year
Number of kms to work
Number of Claims in past 6 years
Number of tickets in past 3 years

SECOND VEHICLE:

Year of Vehicle
Make of Vehicle
Model of vehicle
Use  pleasure work commute commercial use
Number of km per year
Number of kms to work
Number of Claims in past 6 years
Number of tickets in past 3 years
Address
Birthdate
Type of dwelling
Replacement value
Year built

Claims in past 10 years  yes no
Fire Alarm  yes no
Intrusion alarm  yes no
Mortgage  yes no
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