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SOUMISSION
INSTANTANÉE Système intelligent en assurance

DÉBUTER

Vehicle Insurance

"*" indicates required fields

Step 1 of 3

Vehicle insurance type*

Name*

First Last

Email to receive the submission*

Important! Your submissions will be returned to you at this address.

Profession*

Address*

Street Address Address Line 2 City Province Postal Code

Birthdate*

Main phone*

Other phone

Sex*

Civil status*

Spouse's name

First Last

Spouse's name*

How many years have you been living at the same address?*

Number of vehicle(s) to be insured*

Vehicle 1

Date of purchase of the vehicle?*

Vehicle brand*

(Toyota, Honda, etc...)

Vehicle model*

(Exact model, eg Civic LX, SI, two doors, four doors, coupe or hatchback, etc ...)

Main driver*

Vehicle Year*

Indicate your annual mileage*

Price paid (in $)*

State*

Term*

Funding*

Véhicule 2

Date of purchase of the vehicle?*

Vehicle brand*

(Toyota, Honda, etc...)

Vehicle model*

(Exact model, eg Civic LX, SI, two doors, four doors, coupe or hatchback, etc ...)

Main driver*

Vehicle Year*

Indicate your annual mileage*

Price paid (in $)*

State*

Term*

Funding*

Vehicle 3

Date of purchase of the vehicle?*

Vehicle brand*

(Toyota, Honda, etc...)

Vehicle model*

(Exact model, eg Civic LX, SI, two doors, four doors, coupe or hatchback, etc ...)

Main driver*

Vehicle Year*

Indicate your annual mileage*

Price paid (in $)*

State*

Term*

Funding*

Driver information

How long have you had your driver's license?*

This does not include temporary permits, only learners’ permits and permanent licenses.

Type of driver’s license*

Permit number (optional):

By entering your driver's license number, the submissions you receive will be much more accurate.

Has your license been revoked or suspended in the last 6 years?*

Date of revocation

Number of months of revocation

Reason(s) for revocation

Claim or loss with or without disbursement during the last six years

To be more precise, indicate the date of the incident, the amount claimed, and the percentage of responsibilities. Example: 0%, 50%, 100%.

Do you have a court file?*

Traffic violations during the last three years

Indicate the reasons for the infractions and the number of points lost.

Name of current insurer*

Number of years you have done business with this company

Date your insurance could come into effect*

This date is for*

Distance traveled to work or school (in km)*

One-way

Annual mileage for business only

To visit clients or business meetings.

You are now on the last step of the form. You will probably find some questions that seem out of context; however, all questions can affect your premium and give you very good discounts on your quote.

Name of your employer*

Enter the position held with this employer

How many employees, on average, are there at your workplace?

University diploma

Member of CAA-Quebec*

Your car has a lock*

Type of anti-theft system

Example: intensive markings, anti-starter, smart key, tracking system

Did you take a driving course?*

Number of children under 16 living with you

What kind of bonus would you like to receive with this submission?

Public liability*

Collision deductible*

Deductible (fire, theft, vandalism, broken glass)*

New value*

In order to give you the best possible quote, will you allow us to check your credit rating and claim record?*

Contact preference

De jour

De soir

De fin de semaine

En tout temps

How did you hear about us?

Combined with

Life Insurance: 3 additional questions (10 seconds)

Comments

Terms and conditions of use*

I agree with the terms and conditions of use

Date

Home Insurance

"*" indicates required fields

Step 1 of 6

Preferred type of home insurance:*

Name*

First Last

Email to receive the submission*

Important! Your submissions will be returned to you at this address.

Profession*

Name of your employer*

Address*

Street Address Address Line 2 City Province Postal Code

Combined with

Vehicle Insurance

Birthdate*

Main phone*

Other phone

Sex*

Civil status*

Spouse's name*

First Last

Birthdate*

Spouse's job*

Name of spouse's employer*

Hidden

Home Insurance - Owner & Chalet

Date of acquisition of your property*

Year built*

Type of residence*

Type of building*

Roof type*

Number of bathrooms*

Main heating system*

Amount of wooden cord used annually

Other heating source

Do you have a garage?*

Garage type*

Garage heating system (if heated)

Approximate cost of replacement (in $)*

The year your water heater was replaced*

Does your house have a basement?*

percentage of the finish of the basement*

Approximate size of your home*

Distance from your home to the nearest fire hydrant*

Distance from your home to the nearest fire station*

Is your residence connected to a fire and theft center?*

Are the occupants of your residence non-smokers?*

Do you have a pool?*

Type of installation*

Year of installation*

Do you have a spa?*

Year of installation*

Do you have a wood lot?*

Do you have a hunting camp?*

Do you have an accredited or private daycare?*

Renovations done to your home since its construction (ex: roof, window, plumbing) and date of renovations*

Does your residence have a backflow valve?*

How much coverage do you have for rebuilding your building?*

How much coverage do you have for ground-level water damage and sewer backup?*

Hidden

Home Insurance - Tenant

Number of housing in your building?*

Your home is on which floor?*

Number of bathrooms*

Hidden

Home Insurance - Co-owner

Date of acquisition of your property*

Number of housing in your building?*

Your home is on which floor?*

The year your water heater was replaced*

Number of bathrooms*

Vehicle Insurance

Number of vehicle(s) to be insured *

Vehicle 1

Date of vehicle purchase*

Vehicle brand*

(Toyota, Honda, etc...)

Vehicle model*

(Exact model, eg Civic LX, SI, two doors, four doors, coupe or hatchback, etc ...)

Main driver*

Vehicle Year*

Indicate your annual mileage*

Price paid (in $)*

State*

Term*

Funding*

Vehicle 2

Date of vehicle purchase*

Vehicle brand*

(Toyota, Honda, etc...)

Vehicle model*

(Exact model, eg Civic LX, SI, two doors, four doors, coupe or hatchback, etc ...)

Main driver*

Vehicle Year*

Indicate your annual mileage *

Price paid (in $)*

State*

Term*

Funding*

Vehicle 3

Date of purchase of the vehicle*

Vehicle brand*

(Toyota, Honda, etc...)

Vehicle model*

(Exact model, eg Civic LX, SI, two doors, four doors, coupe or hatchback, etc ...)

Main driver*

Vehicle Year*

Indicate your annual mileage *

Price paid (in $)*

State*

Term*

Funding*

Driver information

How long have you had your driver's license?*

Type of driver’s license*

Permit number (optional):

By entering your driver's license number, the submissions you receive will be much more accurate.

Has your license been revoked or suspended in the last 6 years?*

Date of revocation

Reason(s) for revocation

Number of months of revocation

Claim or loss with or without disbursement during the last six years

To be more precise, indicate the date of the incident, the amount claimed, and the percentage of responsibilities. Example: 0%, 50%, 100%.

Traffic violations during the last three years

Indicate the reasons for the infractions and the number of points lost.

Date your insurance could come into effect*

This date is for*

Distance traveled to work or school (in km)*

One-way

Annual mileage for business only

To visit clients or business meetings.

Your car has a lock*

Type of anti-theft system

Example: intensive markings, anti-starter, smart key, tracking system

Did you take a driving course?*

What kind of bonus would you like to receive with this submission?

Public liability*

Collision Franchise*

Franchise (fire, theft, vandalism, broken glass)*

New value*

JE DÉSIRE ÊTRECONTACTÉ PAR Courtier et/ou assureur

SOUMISSIONINSTANTANÉE Système intelligent en assurance

Vehicle Insurance

Vehicle 1

Véhicule 2

Vehicle 3

Driver information

What kind of bonus would you like to receive with this submission?

Home Insurance

Home Insurance - Owner & Chalet

Home Insurance - Tenant

Home Insurance - Co-owner

Vehicle Insurance

Vehicle 1

Vehicle 2

Vehicle 3

Driver information

What kind of bonus would you like to receive with this submission?

Additional information

JE DÉSIRE ÊTRE
CONTACTÉ PAR Courtier et/ou assureur

SOUMISSION
INSTANTANÉE Système intelligent en assurance