Canadian Independent Auto Insurance Advisor & Broker

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Courriel:
daniel.latour@
justincaseinsurance.com

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danielallanlatour@yahoo.com

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latourdaniel@msn.com

Skype:
daniel.la.tour

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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:
1-888-245-5505

World Headquarters:
147 Place Terry Fox
Kirkland, Quebec
CANADA H9H 4Z5

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Save Time & Money. Free, Fast & Easy To Apply. Auto, Classic Cars, Motorcycle, Van, Truck & RV's Tell us about yourself
Province:
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 violatio 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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