Refer me

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I’d like to refer your services to:

Ms. Mr.

First name *

Last name*

Telephone *

Type of insurance *

Please indicate the date and time at which we should call this person *

a.m.

p.m.

evening

weekend

I don’t know

Referred by:

First name*

Last name*

Relationship to the person you are referring *

Comments

The information provided will be used to follow up on the contact request. A damaged insurance agent will contact this person to complete an insurance quote based on his or her needs and to offer competitive rates.

Contact Information

Jean-Philippe Godin

Damage Insurance Agent

2466, rue Georgina-Lefaivre
Québec
(Québec) G1X 5J5

1 855 747-7711

1 866 833-0333