Claim form

For the purpose of confidentiality, please fill in, print and send us this form by fax at (514) 868-6420. Your application will be processed within 24 working hours.


Insurance Company :

Client No. :
Insurance Policy No. : Expiry Date
(dd-mm-yy)


Claim Date (dd-mm-yy):
Informed Dale Parizeau Morris Mackenzie via fax on (dd-mm-yy):


Last Name of Policyholder : First Name :
Address : City :
Province : Postal Code :
Home Telephone : Office Telephone :


Vehicle (year-make-model) : Serial No. (ID) :
License Plate No : Creditors :


Last Name of Driver of Insured Vehicle (during claim) : First Name :
Address (if different from policyholder) : City :
Province : Postal Code :
Home Telephone : Office Telephone :
Driver’s License No. :




Claim Location :



Circumstances of Claim: (select one of the following options)
Car

Collision :
Vandalism :
Theft :
Fire :
Other :
(Specify below)
  
Home

Theft :
Fire :
Water Damage :
Civil Liability :
Other :
(Specify below)
  




Other Information (e.g. Police report no., etc.)

 




Third-party (information on other person involved) :

 




Where is your vehicle now (garage address and telephone) ?

 




Description of damage to vehicle (or residence)






Insurance and financial services firm              All rights reserved 2008. DALE PARIZEAU MORRIS MACKENZIE