General Information

Mr.Mrs.

*First name :

*Last name :

*Phone :

Applicant

Company name :

Current insurer :

Policy expiration date :

*Does your company belong to a group, association or professional order?YesNo

If yes, which group, association or professional order does your company belong to?

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

Type of business and protections

Industry :

Company size :Small or Medium EnterpriseMedium or Large Enterprise

Annual sales :

Copy of your current insurance policy
*Max size 15mb

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.

Stay connected

Email:

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

Questions / Comments

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