General Information

Mr.Mrs.

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Applicant

Do you belong to a group, association or professional order ?YesNo

If yes, which group, association or professional order do you belong to?

What kind of coverage are you interested in ?Personal Lines InsuranceCommercial Lines InsuranceLife and Health InsurancFinancial ServicesClaimsOther

*Are you or have you ever been one of our clients ?YesNo

Contact Preferences

When do you want us to call you ?MondayTuesdayWednesdayThursdayFriday

Between 8h30 a.m. and 12h00 p.m.Between 1 p.m. and 5 p.m.

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I hereby authorize Lussier Dale Parizeau to send me information about its products and services by email (I will be able to modify my permission at any time):

Special offers, saving opportunities, contestsYesNo

Newsletter (general information and advice about the company and products)YesNo

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