Cotation ...
1-First name:
2-Family name:
3-Date of birth, Day Month Year
4-Sex: M F 5-Smoker: Yes No
6-Marital Status: Married Single Common law
7-Since what year have you had this marital status (Ex:1990)
8-Date that you obtained your driver's license: Day Month Year
9-Driver's license:
10-Address: 11-Apartement:
12-City: 13-Postal Code:
14-Since what year have you been living at this address (Ex:1992)
15-E-mail:
16-Telephone(home): 17-Tel. (work):
18-Occupation: 19-Fax:
20-Employer:
21-City that you work in:
22-Since what year have you been with this employer (Ex:1990)
Driving Record
Enter your claims for the last six years, claimed or not, fire, theft, vandalism, windshield, windshield repair, responsable or non-responsable .
Date (DD/MM/YYYY) Responsability Type of claim
/ / 0%50%100% TO CHOOSE Other - B3 Windshield repair - B3 COLLISION WITH AN IDENTIFIED VEHICLE - B2 COLLISION - HIT AND RUN - B2 COLLISION WITHOUT THIRD PARTY - B2 FIRE- B3 ICE STORM - WIND - B3 RESP. - Belongings/property damage to others S.G.&C. - A RESP. - Belongings/property damage ($1000.) -A RESP. - Damage to the insured - A RESP. - Damage to the third party - A RESP. - Bodily injury - A RESP. - Total loss -43 - A RESP. - Loss of use - A RESP. - Trailer liability - A VANDALISM -B3 Stolen vehicle -B3 Partiel theft of vehicle -B3 NO CLAIMS
Description
/ / 0%50% 100% TO CHOOSE Other - B3 Windshield repair - B3 COLLISION WITH AN IDENTIFIED VEHICLE - B2 COLLISION - HIT AND RUN - B2 COLLISION WITHOUT THIRD PARTY - B2 FIRE- B3 ICE STORM - WIND - B3 RESP. - Belongings/property damage to others S.G.&C. - A RESP. - Belongings/property damage ($1000.) -A RESP. - Damage to the insured - A RESP. - Damage to the third party - A RESP. - Bodily injury - A RESP. - Total loss -43 - A RESP. - Loss of use - A RESP. - Trailer liability - A VANDALISM -B3 Stolen vehicle -B3 Partiel theft of vehicle -B3 NO CLAIMS
Tickets in the last 3 years or license suspension
Date (DD/MM/YYYY) Points lost
/ /
Information on the vehicule
23-Year : TO CHOOSE 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 ..etc 24-Make(ex:Honda) :
25-Model(ex:Civic CX) :
26-Purchase price : 27-Value when brand new :
28-Serial number of the vehicle:
29-Actual number of kilometers : 30-Number of Km done annually :
31-Is there an anti-theft installed ? Yes No
If yes, what kind ?
32-Purchase date of the vehicle ? Day Month Year
33-How would you like to insure your automobile ?
Civil liability only
Civil liability and fire/theft
Civil liability, fire/theft and vandalism/windshield
Complete protection with convey courtesy
Complete protection without convey courtesy
Complete protection with convey courtesy and without replacement cost
Complete protection with convey courtesy and with replacement cost
34-Enter the number of vehicles at your residence
35-Enter the number of driver's at your residence
36-Do you work on the island of Montreal ? Yes No
37-Choose the type of use for your vehicle ? TO CHOOSE Affaire Promenade Work Utility
38-Enter the approximate number of kilometers for you to drive to work(if not used enter 0)
You can enter additional information that you judge to be of importance in order to properly protect your automobile.
How to contact you ?
39-What is the best time to contact you ? Day Night No specific time
40-Do you have insurance with us presently (other vehicles,house)? Yes No
41-How would you like an agent to contact you ? By telephone By e-mail
42-The insurance is require for what date ? Day Month Year
43-This quotation is for a ? Renewal New purchase
Actual premium
44-How long have you been mentioned on an insurance contract (years) ?
45-Who is your insurer(if you don't have one mark: none) ?
46-Is the vehicle leased or financed ? Yes No
47-Have you ever been refused an insurance contract or renewal ? Yes No
48-Has your driver's license ever been suspended ? Yes No
49-Would you accept that the insurance company verify your credit score to establish a better premium? Yes No
How did you discover our internet site ? TO CHOOSE Search engin(ex: Yahoo) Yellow pages Yellow pages internet ProprioQuebec.com Friend - reference Via our advertisements of setting on standby Via our advertisements by e-mail