Quote request form

Personal Property Insurance quote request form for Assurances Gaucher & Robert Inc.

For Québec Province resident only.

* Please fill in the fields followed by a star.

General Information The information in this section belongs to the insurance policy holder.
First name *	Name *
Address *	City *
Postal code *
Telephone (Home) * - -	Telephone (Work) - - #
Email
Insured birth date - -	Spouse birth date (if applicable) - -
Occupation of Insured	Occupation of Spouse (if applicable)
Name of employer	Name of employer (Spouse)
Are you a student? Yes No	If yes, what is your present education level?
Are you a first cycle university graduate? Yes No
Indicate the residence date of purchase or the date you moved to this adress. - -
If you have been living at this adress for less than three years, please indicate your previous adress:
Former address	City
Postal code
In order to apply the best possible conditions in establishing your premium, would you allow us to check your credit and loss history with external firms holding this information?
Current insurer	Renewal Date - -
Type of policy requested