Online Request for PAXI Members Discover the different types of coverage available, and we will guide you to the one that best suits your needs! General Information of the Taxi Owner First Name Last Name Email Email Address City Postal code Phone Number On what date must the insurance contract enter into force: Insurance Coverages Requested Vehicle liability insurance – $2,000,000 Option #1 : Chapitre B1 - All risks (including accident with collision and all damage to the vehicle other than the collision) Yes No Option #2 : Chapitre B3 - Accident without collision without payment (includes all damage to the vehicle other than the at-fault collision) Yes No Information on Taxi Vehicle year (optional) Vehicle make (optional) Vehicle model (optional) Vehicle VIN (optional) Vehicle value (optional) Do you have a GPS tax call dispatch system? Yes No Does the vehicle have 3 batteries or more? Yes No Is the vehicle modified for paratransit? Yes No Do you have a POS (credit card modem)? Yes No Vehicle use - Select -TaxiLimousineSpecialized TransportationOther activities Is the vehicle used 100% for the taxi? Yes No Are there any advertising signs on the vehicle? Yes No Driver's Declaration (if different from owner) First Name (optional) Last Name (optional) Email Email Date of birth (optional) Number of years of experience in class 4C or as a taxi driver Has the SAAQ added any conditions to your license, such as wearing glasses? Yes No Number of years as a taxi owner (optional) Which metropolitan area do you depend on (optional) Have you been involved as an owner or user of a motor vehicle taxi, in any claim(s), with or without indemnity, in the last 4 years. Yes No Have you been convicted or disqualified from driving as a motor vehicle operator under the Highway Traffic Act or the Criminal Code in the past 3 years Yes No Has your driver's license been suspended or revoked in the last 5 years? Yes No Do you or any member of your household have a criminal record? Yes No Are you the only driver driving this vehicle? Yes No How many drivers will drive this vehicle? (optional) - None -12345 Do you have drivers under the age of 25? Yes No Information on your current insurer Previous insurer (optional) Policy number (optional) Has an insurer cancelled your policy or refused to renew it Yes No Important Notes The insurance that may result from the above declarations is subject to the provisions and clauses of the Quebec automobile insurance policy (Q.P.F. no. 1). By submitting this form, I authorize and request any current and former insurer and/or employer to provide Northbridge Insurance Company and its agents with a detailed list of claims that have occurred as well as all other information, personal or others, relevant to the formation, execution and monitoring of this contract.
