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Courriel:
daniel.latour@
justincaseinsurance.com

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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. Home, Cottage, Condo, Tenant & Commercial Insurance Your Personal Data:

Province:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):


Dwelling Information

Year Home Built:
Home Square footage:

Fireplace	NO YES(woodburning) YES(gas)

Month/Year home to be complete:

Number of units:	1 family Duplex

Type foundation:	Slab Crawlspace over slab Pier & Post Other (list in remarks)

Type Construction:	Frame Brick/Veneer Stone Other (list in remarks)

Type Roof:	Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other

Number of stories:	One 1.5 Two Three

Do you own animals or pets?	Yes No
Type Of Floors:

Are You Near Brush Area?	Yes No

# of feet to nearest fire hydrant:	# of miles to nearest fire station:

Currently Insured?	Yes No
Name of Carrier & how long insured?

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

Prior Claims?	Yes No
Describe claims in detail:

Rate Your Credit History and Past Insurance Payment History: (Some companies products are based on your credit and payment history.)	Excellent Fair Poor Horrible

Plumbing type:	Copper Galvanized Mixed (Copper/Galvanized)

Circuit Breakers or fuses?	Breakers Fuses

# Bedrooms: # Bathrooms:

# Fireplaces: # Chimneys:

Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)

Coverages:

Dwelling Cov. $ Contents $

Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)

Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):

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