Complete the form

Consumer

Gender *

Mr

Mrs

First name *

Last name *

Address *

City *

Province *

Postal Code *

Phone (home) *

Phone (work) *

Last Insurer on Risk

Name

Policy number

Expiration

Please send us a copy of your automobile insurance contract:

Last Broker on Risk

Name

Phone

Cancellation (if applicable)

Date

Please give a brief explanation of the problem

Insurance Companies or brokers contacted having refused coverage (minimum 5 contacts)

1- Company name / Broker's name *

Phone *

Contact's name *

2- Company name / Broker's name *

Phone *

Contact's name *

3- Company name / Broker's name *

Phone *

Contact's name *

4- Company name / Broker's name *

Phone *

Contact's name *

5- Company name / Broker's name *

Phone *

Contact's name *

Do you hold any other insurance coverage?

Home

Company name

Policy no.

Auto

Company name

Policy no.

Buisiness

Company name

Policy no.

I hereby authorize Groupement des assureurs automobiles, in their actions on my behalf to identify an insurance company which may be prepared to provide me with an automobile insurance policy, to:

check the personal information given to GAA with insurance companies and brokers you have contacted
obtain from such insurance companies and brokers any other missing personal information relevant to the underwriting of the risk, and do you authorize such insurance companies and brokers to disclose this information to GAA;
disclose to an insurance company or broker that you have not contacted any personal underwriting information required if GAA approaches such an insurance company or broker to try and obtain an automobile insurance policy on your behalf.

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Automobile Insurance Availability form

Consumer

Last Insurer on Risk

Last Broker on Risk

Cancellation (if applicable)

Insurance Companies or brokers contacted having refused coverage (minimum 5 contacts)

Do you hold any other insurance coverage?