Full name and address of the named insured	If trade name with no legal entity (Reg’d) indicate also owner’s name	French policy	R E P R E S E N T A T I V E
Broker No.	CONTRACT PERIOD
12.01 A.M. Standard time at the address of the named insured
Postal code	FROM	DAY	Month	Year	TO	Day	Month	Year	as to each of said date
Home tel.	Business tel.	Birthday	BILLING
DD	MM	YY
Occupation or business	DIRECT BILLING 8	REGULAR (by broker) 0
A PRE-AUTHORIZED CHEQUES Complete the “Auto pre-autorized cheques authorization form” B PAYMENT IN FULL BY CHEQUE
The described vehicle is and will be mainly used, stored and parked in the town/city and province shown above. If not, the client or the named insured must so declare.
Particulars of the described vehicle
Veh. No.	VEH. CODE	YR.	MAKE	MODEL	TYPE OF BODY INCLUDING NUMBER OF DOORS	CC (Misc. veh.)	SERIAL NUMBER (full and correct)	BODY CODE
1
2
Veh. No.	Purchase date	CONDITION WHEN BOUGHT	PURCHASE PRICE (incl. equip. & taxes)	LIST PRICE NEW	Is the vehicle leased or under a contract of leasing? If so, fill in section “ADDITIONAL INTEREST” on the reverse side.	WEIGHT (Commercial auto.)
Month	Year	net (kg)	gross (kg)
1	New N	Used U	Demo. D	Yes No
2	New N	Used U	Demo. D	Yes No
Veh. No. 1 Yes No	Veh. No. 2 Yes No
1. Has the vehicle been modified in any substantial way or has it been repainted in any special manner?	D E S C R I B E
2. Machinery: is there any machinery or equipment mounted on or attached to the vehicle? (ex.: cellular phone, crane, loader, etc.)
3. Is the vehicle powered by fuel other than gasoline or diesel?
The vehicle will be chiefly used for the following purposes:

Veh. No.	PLEASURE	PLEASURE AND BUSINESS	RECREA- TIONAL VEHICLE	PRIVATE TRAILER	OTHER PURPOSE	VEHICLE TOTAL ANNUAL KM
Pleasure shall be regarded as including the use of the vehicle as transportation between the place or residence and the place of work	P P	Number of kilometers one way or part way to drive to work or to school	Km	No delivery	Meal delivery	Other delivery	Annual business KM	Other	Describe use if other than pleasure and business
1	F	S	L	R	T	A
2	F	S	L	R	T	A
Veh. No.	UTILITY MOTOR VEHICLE ONLY Normal radius of operations of the vehicle	PRIVATE VEHICLE ONLY The principal driver of the MM YR.	UTILITY VEHICLE ONLY The named insured continuously MM YR.	OCCUPATION OR GROUP CODE	State place where the vehicle is and mainly used, stored and parked if different from the named insured's address:
1	Km	described vehicle which has been continuously insured as principal driver of a similar vehicle since:	insured as owner or lessee of the described vehicle or any other replacement utility vehicle since:
2	Km
This application is made for insurance against one or more of the perils mentioned below, but for insurance under section(s) or subsection(s) for which a premium is specified herein for the following specified limit(s) and amount(s).
Veh. No.	COVERAGE	SECTION A Civil liability	SECTION B Damage to insured vehicles	Q.E.F. No. 34 Accident benefits insurance	ENDORSEMENTS
PERILS	Property damage or bodily injury to another person (Mandatory insurance)	Amount deductible on each separate claim except for loss or damage by fire or lightning	Medical expenses by person	Death, dismemberment principal sum	Total disability Maximum per week	INOV	Discount for absence violations	REPLACE-MENT COST	ANTI- THEFT SYSTEM	D E S C R I B E
All perils	Collision and upset	All perils other than collision or upset	Specific perils
1	AMOUNT OF INSURANCE AND DEDUCTIBLE	Yes	Yes	Yes
2	Yes	Yes	Yes
1	INSURANCE PREMIUM
2
*OCCA- SIONNAL	* To be used for occasoinal male driver under 25 years of age.	Total net insurance premium
Additional information relating to the vehicle	Veh. No. 1	Veh. No. 2
Is the vehicle used outside of Quebec?	Yes	No	Yes	No
If yes: number of weeks per year (consecutives or not): Veh. No. 1	wk.	Veh. No. 2	wk.	Province or State: Veh. No. 1	Veh. No. 2
Will the vehicle be rented or leased, or used for carrying passengers for compensation or hire, or for carrying explosives or radioactive material?
If so, state particulars
Will the vehicle be used for the transportation of goods for compensation? If so, fill in section “TRANSPORTATION OF GOODS FOR OTHERS” on the reverse side.
Will the vehicle be operated by any person suffering from the loss of, or loss of use of, an eye, hand, foot or limb, or who is physically or mentally disabled to an extent that might affect the safe operation of a vehicle? If so, state particulars in section “DRIVERS” on the reverse side.
The named insured is both the actual owner and the registered owner of the described vehicle.
If not, the following information must be provided: A) THE REGISTERED OWNER	B) THE ACTUAL OWNER
Rating – To be filled in by broker (the information included herewith is in no way binding on client or the named insured)
Veh. No.	TERR.	DRIVERS PRINCIPAL OCC. MALE	DISTINCTION PROGRAM	DISTINC. PLUS	VEH. GROUP	DISCOUNT	MISCELLANEOUS
Classe – Record	Age	Classe – Record	Female driver 25 or over	Spouses 2 or more auto (C63)	Occupation or group	Recreational motorcycle	Other
1	06-	Yes	Yes
2	06-	Yes	Yes

150-FL-809.14 (04-19)

Transportation of goods for another person	Veh. No. 1	Veh. No. 2
State:	- approximate value
- type of goods carried
Name of Insurer of Motor Truck Cargo Insurance:
Policy No.	Amount of insurance	Deductible
Statement of eligibility for distinction program – private passenger or utility vehicles only
I, the undersigned, certifies that: Private passenger vehicle only. The principal driver of the described vehicle is the principal driver of a private passenger vehicle which has been continuously insured for at least the last 3 years. Utility vehicle only. I have been continuously insured for at least the last 3 years as owner or lessee of the vehicle described on the reverse side or any other substitute commercial vehicle. Private passenger vehicle. During the same 3 years period, the drivers of the vehicle: have not been involved in any accident regardless of liability, have not been convicted under the Criminal Code for violation under any law or statute governing road traffic, and have not been convicted for more than one violation under any law or statute governing road traffic. Private passenger or utility vehicle. Futhermore, during this same 3 year period, the described vehicle or any other substitute vehicle has not been involved in any accident, regardless of liability, and has sustained no insurable loss or damage in accordance with Sections A and B. APPLICABLE TO: Veh. No. 1 Veh. No. 2
Drivers
Veh. No.	Driv. No.	NAME AND SURNAME	SEX M F	CIVIL STATUS	TYPE OF DRIVER	DRIVER'S LICENCE	DRIVING COURSE	RELA- TION- SHIP	Driver is automobile insured with Intact Insurance since:	AUTHORISATION SAAQ
OR DRIV. EXP.	HELD SINCE	NUMBER	ISSUING JURIDICTION
PRINC.	OCC.	QC	OTHER SPECIFY	YES NO
NB MS	MONTH	YEAR	Mth	Yr.	YES	NO
Driv. No.	M – Married C – Single V – Wildowed D – Divorced S – Separated F – Cohabitee E – Ecclesiastic A – Other	A – Insured C – Spouse E – Child F – Brother or sister M – Mother of father X – Other
Occupation	Employer (name and address)
Occupation	Employer (name and address)
Occupation	Employer (name and address)
Disability – date	Description
Violation/Suspension: Within the three years preceding this application and to the knowledge of the named insured or yours – has any licence, permit, registration certificate or other like authority, issued to the named insured or a member of his household under any law or statute of any province, state or county relating to vehicles been, or continued to be, suspended or cancelled – or has the named insured or a member of his household been convicted of a violation under any law or statute governing road traffic? Yes No If so, state particulars (date, type and driver):
Fichier central
The client has been informed that the insurance company may ask and obtain, for underwriting and rating purposes, information regarding his claims record from the Fichier central des sinistres automobile. Yes No
Accident – Losses – Claims
State, in view of relevant headings listed opposite, particulars of all accidents, losses or claims arising out of the ownership, use or operation of any vehicle by the named insured or spouse within the six years preceding this application:	Property damage or bodily injury caused to another person, Damage to vehicle owned an/or operated by the named insured or spouse arising from: a) Collision b) Other perils
Veh. No.	Driv. No.	CLAIM FILE	DATE	SETTLED	LIABLE	KIND	SEC.	AMOUNT	DETAILS
Day	Mth.	Yr.	Yes	No	Yes	No
Additional interest
Veh. No.	C = CREDITOR L = LESSEE Full name and address
Cancelled or declined previous insurance
Within the three years preceding this application, has any Insurer, to the knowledge of the named insured or yours, cancelled, declined or refused to renew or issue automobile insurance to the named insured or spouse? Yes No If so, state name of Insurer.
All the statements herein are true and the named insured and the client hereby applies for a contract of insurance to be based on the truth of the said statements. Any misrepresentation or deceitful concealment on the part of the client or of the named insured in connection whith facts known to him and likely to materially influence a reasonable Insurer in the setting of the insurance premium and the appraisal of the risk or the decision to cover it, nullifies the contract at the instance of the Insurer, even for losses not connected with the risks so misrepresented.
Notice to the client
Information submitted with your application may be compared with information obtained from the Fichier central des sinistres automobiles (Claims Master File). Any discrepancy will be communicated to you directly or through your broker, who is presumed to have been authorized by you to receive information from the Fichier central.
DATE	SIGNATURE OF CLIENT*
*Client: the person who submits an application to the insurer in order to enter into an insurance contract. The client may be the named insured or another person.
Broker’s report
Previous Insurer	Policy No.
Broker’s auto insurance customer since:	Holder of auto insurance since:
If eligible for SYNCHRO program, state dwelling policy No. associated with auto insurance
Other insurance with Intact Insurance, policy No.
DATE	SIGNATURE OF BROKER
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