Any other notice of loss

Any other notice of loss

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
Requis

Province*
Requis

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

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

Is the address of the damage identical to that of the domicile?
Please answer

If "No" please provide damage address information

Address
Required

City
Required

Province
Requis

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

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