Automobile insurance

In order to receive your automobile quote quickly, complete the following form making sure to fill in all the boxes pertaining to your situation.

To send, click on the button: SEND FORM.

Disposing of all the information, we will be able to offer you all the rebates you might qualify for and find the product that best answers your needs.

The insured

Last name
First name
Address (no, street, apt.)
City
Postal Code
Post Office Box
Your email

THE DRIVERS

	Driver A	Driver B	Driver C
Last name
First name
Date of birth
Sex
Marital status
Employment
Did you follow driving lessons?	yes no	yes no	yes no
If yes, state name of school
Owner of a driving permit since	year	year	year
Détenteur Owner of car insurance since	year	year	year
Owner of a car since	year	year	year
How many demerit marks (3 last years) ?
If applicable, number of occurrences
Permit suspension (6 last years) ?	yes no	yes no	yes no
Have been refused or suspended an automobile insurance (3 last years)	yes no	yes no	yes no
If yes, reasons
Present or previous insurance company
Claims in the last 6 years
Date of claim (#1)
Amount and nature of claim (#1)
Percentage of responsibility (#1)
Date of claim (#2)
Amount and nature of claim (#2)
Percentage of responsibility (#2)
Other claims? (If yes, specify in ‘Commentary’ section at the end of the page)	yes no	yes no	yes no

YOUR VEHICLES

	Vehicle no 1	Vehicle no 2
Make
Model
Number of doors
Year of make
Main driver
Secondary driver(s)
Distance to work
Yearly odometer
Anti theft	yes no	yes no

DESIRED COVERAGE

Important note : To facilitate your choices, consult your present car insurance, if applicable. In your policy summary, you will find the coverages under: ‘chapters A, B1, B2…’. If this is your first application for car insurance or if your are unsure of certain coverage titles, do not write anything and explain in the following ‘Commentary’ section. The civil liability coverge is mandatory, required by Automobile Insurance Law of Quebec).

	Vehicle 1	Vehicle 2
Civil liability	1 000 000 2 000 000	1 000 000 2 000 000
For your Vehicle	Aucun All risks (B1) - deductible 250$ All risks (B1) - deductible 500$ All risks (B1) - deductible 1000$ Collision (B2) - deductible 250$ Collision (B2) - deductible 500$ Collision (B2) - deductible 1000$ Accident without collision (B3) - deductible 50$ Accident without collision (B3) - deductible 100$ Accident without collision (B3) - deductible 250$ Accident without collision (B3) - deductible 500$	Aucun All risks (B1) - deductible 250$ All risks (B1) - deductible 500$ All risks (B1) - deductible 1000$ Collision (B2) - deductible 250$ Collision (B2) - deductible 500$ Collision (B2) - deductible 1000$ Accident without collision (B3) - deductible 50$ Accident without collision (B3) - deductible 100$ Accident without collision (B3) - deductible 250$ Accident without collision (B3) - deductible 500$

COMMENTARIES AND QUESTIONS

If you wish to contact us directly, don’t hesitate to call or write.

Telephone: (418) 654-2933
Fax: (418) 654-1244
E-mail: info@aspro.qc.ca