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E-Mail:
daniel.latour@
justincaseinsurance.com

MSN Messenger:(Live Chat)

latourdaniel@msn.com

Skype:
daniel.la.tour

1-888-977-7778 Monday-Friday 9-9, Saturdays 11-5, EST. Our International Number is: 1-514-630-6116

Toll-Free Fax:
1-888-637-2636

Courrier Address:
147 Place Terry Fox
Kirkland, Quebec
CANADA H9H 4Z5

Regional Offices:
410-2001
McGill College Avenue
Montreal, Quebec
CANADA H3A1G1

200-1122 4 Street SW
Calgary, Alberta
CANADA T2R1M1

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Save Time & Money. Free, Fast & Easy To Apply. Auto, Classic Cars, Motorcycle, Van, Truck & RV's Your Personal Data
Your Name:
Street Address:
City:
Province:
Postal Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

Current Policy Renewal Date (MM/DD/YR)?

DRIVER INFORMATION #1
Name:
Birthdate:
Sex (M/F):		# Years Canada Licensing:
Drivers Permit or Registration ID#:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Citations last 3 years:
Number & Type of MAJOR Citations last 3 years:		Daily commute in ONE WAY miles:
G1, G2 and G licence dates (if applicable.)		Any cancellations for non payment or suspensions?

DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:		# Years Canada Licensing:
Drivers Permit or Registration ID#:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Citations last 3 years:
Number & Type of MAJOR Citations last 3 years:		Daily commute in ONE WAY miles:
G1, G2 and G licence dates (if applicable.)		Any cancellations for non payment or suspensions?
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:		Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of Liability:	$50/100 BI / 50 PD Liability`$100/300 BI / 50 PD Liability $250/500 BI / 100 PD Liability`

Comprehensive Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Collision Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Uninsured Motorists Coverage?	YES NO

Rental Car & Towing Coverage?	YES NO

Medical and/or PIP Coverage?	YES NO

VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:		Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of Liability:	$50/100 BI / 50 PD Liability`$100/300 BI / 50 PD Liability $250/500 BI / 100 PD Liability`

Comprehensive Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Collision Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Uninsured Motorists Coverage?	YES NO

Rental Car & Towing Coverage?	YES NO

Medical and/or PIP Coverage?	YES NO

Comments or Remarks: (List additional drivers, autos, etc. here)
If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:

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Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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