Quality product insurance that will meet all
your needs at the best guaranteed prices!
Français
New file
Note: The items preceded by a
red star * are obligatory fields.
file no :
police no :
*
First Name :
*
Last Name :
*
Company :
*
Independant adjuster office :
*
Address :
*
City :
*
Province :
*
Postal code :
*
Telephone :
*
Fax :
Cellular :
Pagette :
Email :
Others :
Comments :
*
Insured :
*
Last Name :
*
First Name :
*
Address :
*
City :
*
Province :
*
Postal code :
*
Telephone :
Cellular :
Pagette :
Email :
Others :
*
Calling delay :
low (24 hours)
Normal (4 hours)
High (1 hours)
*
Evaluation :
Evaluation of Replacement
Evaluation of Repair
*
Item
Quantity
Mark / Model or description
$ Amount
Year
(C) 2004 by Techni-service Assurance
