Quote request form

Commercial Insurance quote request form for Assurances Gilles Bazinet Inc.

For Québec Province resident only.

* Please fill in the fields followed by a star.

General Information
Operating Name *	Attention *
Mailing Address *	City *
Postal code *
Telephone * - - #	Email
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?
Business Type	Renewal Date - -