Refer us

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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

Assurance Maxime Bergeron inc.

Damage insurance agency

761, rue Sainte-Geneviève
Saint-Tite
(Québec) G0X 3H0

1 855 747-7711

1 866 833-0333