GAA

Access request to FCSA Claims History Statement

*Required fields
Requester’s identification
Driver’s licence number *:

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

Date of birth *:
  YYYY
  MM
  DD
Email *:
Email confirmation *:
Language *:
French
English


City *:
Province *:
Country *:
Postal code *:
Your insurer’s name :
Confirmation
I hereby certify that the information given on this form is true and correct.