General Information

Mr.Mrs.

*First name :

*Last name :

*Phone :

*City :

*Date of birth :

Applicant

*Are you ?Canadian TravellersExiled Canadian WorkersForeign Exchange StudentsCanadian Visitors

What kind of coverage are you interested in ?Emergency Medical Care / RepatriationLost or stolen baggageTrip Cancellation and Interruption

Are you interested by:Annual Travel InsuranceRecuring Travel Insurance

If you are requesting a recurring travel insurance, how long (in days) is each travel interval?

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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