Company Information

Company name :

Company industry :

Approximate annual sales :

Contact person information


*Contact person :

Titre :

*Telephone :


*Office telephone:

Types of Surety

Desired surety coverage :Contract (an offer to be made by telephone)Licences and permits

If you have selected «Licences and permits», please specify :

Additional Informations

Current Surety (Name) :

*Are you or have you ever been one a client of ours ?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.

Stay connected


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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