Automobile first notice of loss

Automobile loss notice

Insured information

First name*
Required

Last name*
Required

Phone number
(999-999-9999)*
Invalide input (ex: 999-999-9999)

Other phone number
(999-999-9999)
Invalide input (ex: 999-999-9999)

E-mail (exemple@test.com)
Invalide input (ex: exemple@test.com)

Date of the incident
(aaaa-mm-jj)
Invalid input (ex: 2018-01-25)

What information do you want to use to identify your insurance policy?*
Select one please !

Membership number
Required

Membership number*
Required

Policy number
Required

Policy number*
Required

Address
Required

Address*
Required

City
Required

City*
Required

Province
Required

Province*
Required

Postal code
(A0B 1C2)
Invalid input (ex: A0B 1C2)

Postal code
(A0B 1C2)*
Invalid input (ex: A0B 1C2)

Driver and vehicle information involved in the accident

Driver name involved
Required

Involved vehicule

Year
Required

Brand
Required

Model
Required

Is the vehicle able to circulate ?
Required

If "No", where is it stored ?*
Required

Circumstances, damages and all other relevant information
Required

Would you like to attach files to your loss notice ?*
Answer please

You can attach any file relevant to the processing of your request here.
Example: Photos of places, damage, friendly report, sketches of places ...

Attach a file
(jpg, png, pdf)*
Please, attach a file with the following format : jpg, png or pdf

Attach a file
(jpg, png, pdf)
Please, attach a file with the following format : jpg, png or pdf

Attach a file
(jpg, png, pdf)
Please, attach a file with the following format : jpg, png or pdf

Invalid Input