Sponsorship

All fields identified by an asterisk (*) are mandatory.

5 + 3

Describe the organization you are applying for financial support

Organization*

Address*

Web site

Phone number*

Non-profit organization* Yes No

If yes, identification number*

Is your organization among our customers* Yes No

Describe the nature of your request (500 characters max.) *

First name*

Last name*

Position*

Phone number *

Your address*

E-mail address*

E-mail confirmation*

Are you currently an assurancia Customer ?* Yes No

Who is your broker ?*