Consultation request of the FCSA Claims History Statement

*Required fields

Requester’s identification

Driver’s licence number *:

Please join a clear image of your driver’s licence (photo side) *
N.B.: This image is mandatory to submit your request
(supported formats are JPG, JPEG, PNG, GIF, BMP, TIF and PDF)

Civility *:

Mr.

Mrs.

First name *:

Last name *:

Date of birth *:

YYYY

Home phone number :

Work phone number :

Email *:

Email confirmation *:

Language *:

French

English

Address *:

City *:

Province *:

Country *:

Postal code *:

Who referred you? *:

Confirmation

I hereby certify that the information given on this form is true and correct.