If you are unsure of a question, answer to the best of your knowledge. Step 1 of 5 20% Number of registered owner:12Owner #1First name:Last name:Date of birth :Number:Appt:Street:City:Postal code:Province:Since when have you lived at this address?Email:Home phone:Work phone:Cell phone:Preferred contact time:DayEveningWeekendPreferred contact numbers?Home phoneWork phoneCell phoneCurrent situation?HomeownerRentalOtherSend me my quotes via text message (sms):YesNoOwner #2First name:Last name:Date of birth :Number:Appt:Street:City:Postal code:Province:Since when have you lived at this address?Email:Home phone:Work phone:Cell phone:Preferred contact time:DayEveningWeekendPreferred contact numbers?Home phoneWork phoneCell phoneCurrent situation?HomeownerRentalOtherSend me my quotes via text message (sms):YesNo InformationsThe reason for requesting a quote:Renewing insuranceBuying a vehiclePlanning to buy vehicleHow did you hear about Assurance Confiance?Friends referral / FamilyInternetSocial MediaPolicy effective date:Home insurance renewal date (if applicable):Current insurer:Current annual premium:How many years are you insured?How many years have you been insured with this insurer?Have you ever declared bankruptcy?YesNoAre you released?YesNoIn the past 10 years, have you or anyone living with you been convicted of a criminal offence?YesNoIf so, explain why:Do you allow access to your credit rating and accident history?YesNo DRIVERSNumber of drivers123DRIVER #1 First nameLast name:Date of birth:Driving licence numbers:Gender:MaleFemaleMarital Status:MarriedSingleWidowedDivorcedCommon-lawLevels of education attained:High school / Professional / Vocational diploma (DEP)College / TechnicalUniversityOtherOccupation:Private sector employeeFederal government employeeProvincial government employeeMunicipal governmentPara-public sector employeeStudentUnemployedHomemakerRetiredSole proprietorBusiness ownerOtherEmployment field:Employment:Employer:Do you allow the insurer to go check your information with the SAAQ?YesNoType of licence:Valid driver's licenceProbationary driver's licenceLearnersOther provincesUSAOther countriesHave you completed a driver's training course?YesNoAt what age did you obtain a Driver's Licence?How many times your licence been suspended in the last 6 years?None123More than 3If so, explain why:Number of tickets (convictions) within the last 3 years, excluding parking tickets?None12345More than 5If so, detail the violations:How many consecutive years, have you been insured as a primary driver?Never been insuredIn interruption of insuranceLess than one year1 year2 years3 years4 years5 years6 years7 years8 years9 years10 yearsMore than 10 yearsHow many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?None123More than 3If so, expand the reason:Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?None12345More than 5Detailing the claim:DRIVER #2 First name of the occasional Driver:Last name of occasional drivers:Date of birth:Driver license number:Sex:MaleFemaleMarital Status:MarriedSingleWidowedDivorcedCommon-lawLevels of education attained:High school / Professional / Vocational diploma (DEP)College / TechnicalUniversityOtherOccupation:Private sector employeeFederal government employeeProvincial government employeeMunicipal governmentPara-public sector employeeStudentUnemployedHomemakerRetiredSole proprietorBusiness ownerOtherEmployment field:Employment:Employer:Do you allow the insurer to go check your information with the SAAQ?YesNoType of licence:Valid driver's licenceProbationary driver's licenceLearnersOther provincesUSAOther countriesHave you completed a driver's training course?YesNoAt what age did you obtain a Driver's Licence?How many times your licence been suspended in the last 6 years?None123More than 3If so, explain why:Number of tickets (convictions) within the last 3 years, excluding parking tickets?None12345More than 5If so, detail the violationsHow many consecutive years, have you been insured as a second driver?Never been insuredIn interruption of insuranceLess than one year1 year2 years3 years4 years5 years6 years7 years8 years9 years10 yearsMore than 10 yearsHow many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?None123More than 3If so, expand the reason:Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?None12345More than 5Detailing the claim:DRIVER #3 First name of the third driverLast name of the third driverDate of birth:Driver license number:Sex:MaleFemaleMarital Status:MarriedSingleWidowedDivorcedCommon-lawLevels of education attained:High school / Professional / Vocational diploma (DEP)College / TechnicalUniversityOtherOccupation:Private sector employeeFederal government employeeProvincial government employeeMunicipal governmentPara-public sector employeeStudentUnemployedHomemakerRetiredSole proprietorBusiness ownerOtherEmployment field:Employment:Employer:Do you allow the insurer to go check your information with the SAAQ?YesNoType of licence:Valid driver's licenceProbationary driver's licenceLearnersOther provincesUSAOther countriesHave you completed a driver's training course?YesNoAt what age did you obtain a Driver's Licence?How many times your licence been suspended in the last 6 years?None123More than 3If so, explain why:Number of tickets (convictions) within the last 3 years, excluding parking tickets?None12345More than 5If so, detail the violations:How many consecutive years, have you been insured as a driver?Never been insuredIn interruption of insuranceLess than one year1 year2 years3 years4 years5 years6 years7 years8 years9 years10 yearsMore than 10 yearsHow many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?None123More than 3If so, expand the reason:Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?None12345More than 5Detailing the claim: Vehicle Number of vehicles123Vehicle #1 Vehicle make:Model:Vehicle year:Serial number:Current value of the vehicle: (excluding taxes):Do you have a vehicle evaluation?YesNoIf so, it dates from when?Name of the Principal Driver:Name of occasional drivers:Name of young drivers:Date of Purchase or lease:Condition of vehicles on the possession date:NewUsedDemo with less than 12 000 kmDemo with more than 12 000 kmVehicles financing:YesNoIf applicable, which is the creditorIs the vehicle leased?YesNoIf applicable, which is the lessor:Primary use of this vehicle:Pleasure onlyPleasure and travel to work / schoolPleasure and businessNumber of km travelled annually:Number of km to get to work or school:Number of Km for business year (if applicable):Km radius of action for business (if applicable)?Does the vehicle is storage?YesNoIf so, at what location?During the period of use, where the vehicle is parked?Use in a competition:YesNoHas the vehicle been in a serious accident or rebuilt?YesNoIs it currently insured with the new value?YesNoIs it currently insured with the replacement value?YesNoIs the vehicle used outside the province?YesNoIf used outside the province, how many consecutive days maximum?Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?YesNoIf so, what value?Is this vehicle currently uninsured for more than 10 days and insurers refuse to provide coverage?YesNoHas the vehicle been modified for performance at greater than $1000?YesNoIf so, what value?Has the appearance of the vehicle been modified at a cost greater than $1000?YesNoIf so, what value?Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?YesNoStartup Blockage Mechanism:Original manufacturer Anti-theft packageOther typeNoneTracking system:OnstarEconotrackGuardianVigilIntercepterBoomerang / Lojack EspionBoomerang / Lojack Espion AlertBoomerang / Lojack Espion Alert plusTAGOtherNoneAlarm:ViperOther typeNoneEngraving:SherlockDatadotVin-lockOtherNoneSteering Blocking Bar:AutoluckLarlockOtherNone Vehicle #2 Vehicles make:Model:Vehicle yearSerial number:Current value of the vehicle: (excluding taxes):Do you have a vehicle evaluation?YesNoIf so, it dates from when?Name of the Principal Driver:Name of occasional drivers:Name of young drivers:Date of Purchase or lease:Condition of vehicles on the possession date:NewUsedDemo with less than 12 000 kmDemo with more than 12 000 kmVehicles financing:YesNoIf applicable, which is the creditorIs the vehicle leased?YesNoIf applicable, which is the lessor:Primary use of this vehicle:Pleasure onlyPleasure and travel to work / schoolPleasure and businessNumber of km travelled annually:Number of km to get to work or school:Number of Km for business year (if applicable):Km radius of action for business (if applicable)?Does the vehicle is storage?YesNoIf so, at what location?During the period of use, where the vehicle is parked?Use in a competition:YesNoHas the vehicle been in a serious accident or rebuilt?YesNoIs it currently insured with the new value?YesNoIs it currently insured with the replacement value?YesNoIs the vehicle used outside the province?YesNoIf used outside the province, how many consecutive days maximum?Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?YesNoIf so, what value?Is this vehicle currently uninsured for more than 10 days and insurers refuse to provide coverage?YesNoHas the vehicle been modified for performance at greater than $1000?YesNoIf so, what value?Has the appearance of the vehicle been modified at a cost greater than $1000?YesNoIf so, what value?Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?YesNoStartup Blockage Mechanism:Original manufacturer Anti-theft packageOtherNoneTracking system:OnstarEconotrackGuardianVigilIntercepterBoomerang / Lojack EspionBoomerang / Lojack Espion AlertBoomerang / Lojack Espion Alert plusTAGOtherNoneAlarm:ViperOtherNoneEngraving:SherlockDatadotVin-lockOtherNoneSteering Blocking Bar:AutoluckLarlockOtherNone Vehicle #3 Vehicles make:Model:Vehicle year:Serial number:Current value of the vehicle: (excluding taxes):Do you have a vehicle evaluation?YesNoIf so, it dates from when?Name of the Principal Driver:Name of occasional drivers:Name of young drivers:Date of Purchase or lease:Condition of vehicles on the possession date:NewUsedDemo with less than 12 000 kmDemo with more than 12 000 kmVehicles financing:YesNoIf applicable, which is the creditorIs the vehicle leased?YesNoIf applicable, which is the lessor:Primary use of this vehicle:Pleasure onlyPleasure and travel to work / schoolPleasure and businessNumber of km travelled annually:Number of km to get to work or school:Number of Km for business year (if applicable):Km radius of action for business (if applicable)?Does the vehicle is storage?YesNoIf so, at what location?During the period of use, where the vehicle is parked?Use in a competition:YesNoHas the vehicle been in a serious accident or rebuilt?YesNoIs it currently insured with the new value?YesNoIs it currently insured with the replacement value?YesNoIs the vehicle used outside the province?YesNoIf used outside the province, how many consecutive days maximum?Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?YesNoIf so, what value?Is this vehicle currently uninsured for more than 10 days and insurers refuse to provide coverage?YesNoHas the vehicle been modified for performance at greater than $1000?YesNoIf so, what value?Has the appearance of the vehicle been modified at a cost greater than $1000?YesNoIf so, what value?Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?YesNoStartup Blockage Mechanism:Original manufacturer Anti-theft packageOtherNoneTracking system:OnstarEconotrackGuardianVigilIntercepterBoomerang / Lojack EspionBoomerang / Lojack Espion AlertBoomerang / Lojack Espion Alert plusTAGOtherNoneAlarm:ViperOtherNoneEngraving:SherlockDatadotVin-lockOtherNoneSteering Blocking Bar:AutoluckLarlockOtherNone GUARANTEES Vehicle #1 Liability:1.000.000$2.000.000$Collision or upset deductible:No coverage0$50$100$150$250$500$750$1.000$Comprehensive deductible:No coverage0$50$100$150$250$500$750$1.000$# 2: Driving vehicles not designatedYesNo#20A: Travel costs (broad form) (Section B)YesNo#27: Legal liability resulting from damage caused to vehicles of which named insured is not owner (including vehicles provided by an employer) (Section A)YesNo#34: Accident benefit insurance: Death and dismemberment benefitsYesNo#43E: Total loss - Replacement costYesNo# 33: Insurance troubleshooting costsYesNoVehicle #2 Liability:1.000.000$2.000.000$Collision or upset deductible:No coverage0$50$100$150$250$500$750$1.000$Comprehensive deductible:No coverage0$50$100$150$250$500$750$1.000$# 2: Driving vehicles not designatedYesNo#20A: Travel costs (broad form) (Section B)YesNo#27: Legal liability resulting from damage caused to vehicles of which named insured is not owner (including vehicles provided by an employer) (Section A)YesNo#34: Accident benefit insurance: Death and dismemberment benefitsYesNo#43E: Total loss - Replacement costYesNo# 33: Insurance troubleshooting costsYesNoVehicle #3 Liability:1.000.000$2.000.000$Collision or upset deductible:No coverage0$50$100$150$250$500$750$1.000$Comprehensive deductible:No coverage0$50$100$150$250$500$750$1.000$# 2: Driving vehicles not designatedYesNo#20A: Travel costs (broad form) (Section B)YesNo#27: Legal liability resulting from damage caused to vehicles of which named insured is not owner (including vehicles provided by an employer) (Section A)YesNo#34: Accident benefit insurance: Death and dismemberment benefitsYesNo#43E: Total loss - Replacement costYesNo# 33: Insurance troubleshooting costsYesNoADDITIONAL NOTES