Auto insurance quote [ LUSSIER... Your Quebec car insurance broker

Last name

First name

Date of birth

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Gender

M F

Civil status

Education (diploma)

Profession

Employer name

Job status

Home number

Street

Apartment

City

Province

Postal Code

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Email address

Home phone

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Work phone

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Date on which you obtained your Quebec-issued driver’s license

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Date on which the driver became a vehicle’s main driver

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Number of driving offences committed in the last 3 years

Has this driver’s license been suspended in the last 3 years?

Yes No

Name of your current insurance company

Name of your previous insurance company

Number of claims in the last 6 years

In the last 3 years: has the insured or to his/her knowledge, his/her spouse, had an auto insurance contract or renewal refused or terminated?	Yes No

Do you, one of the drivers or someone living at your place of residence have a criminal history?	Yes No
So that we can offer you the best possible conditions during your quotes, do you let insurers check your credit ?	Yes No

* All fields are required This form does not guarantee that you will be insured or are insurable.

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