AssurExperts™

First Name		City
Last Name		Adresse
Phone		Postal code
Office's phone		Email
Date of birth	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Month 01 02 03 04 05 06 07 08 09 10 11 12   Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910
I have a motorcycle license	OuiNon	If so, class indicated on your license	Choose 6A 6B 6C 6D 6R

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Year		Serial Number (optional)
Make		Model
Purchase price (excluding tax, including equipment)		Price when new (excluding tax)
Number of CC

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For the three (3) most recent years, indicate:

Whether your licence has been revoked or suspended, or if you have been found guilty of a criminal infraction.	YesNo

Number of violations less than 3 points	Nothing 1 2 3 4 5 6 7 8 9 10	Number of violations greater than 3 points	Nothing 1 2 3 4 5 6 7 8 9 10

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Type of claims	Date	Liability	Driver
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100%0%
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %
Nothing Collision with third Fire Flight of the vehicle Vandalism Offence hit and run Objet strikes vehicle Bris of pane Réparation windshield Vol of radio/others		100 %0 %

Additional discounts
Occupation		Employer

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Vehicle Coverage
Civil Liability:	All risks:	Collision:	Accident without:	Compensation:
1 million 2 million	Franchise 100 250 500 1500 2000	Franchise 100 250 500 1500 2000	Franchise 100 250 500 1500 2000	YesNo

Date of your RV renewal:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Month 01 02 03 04 05 06 07 08 09 10 11 12   Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910
Name of your current (RV) insurer:?
Residence renewal:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Month 01 02 03 04 05 06 07 08 09 10 11 12   Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910
Comments:
Please contact me	Yes No

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