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Auto Insurance Information

How many at fault claims have you had in the last 3 years?

Vehicle Plate Number

Contact Information

First Name

Last Name

Preferred method of contact



Driver Information

Has your driver's licence been suspended during the last 5 years

How many traffic convictions have you had within the last 5 years?

What is your vehicle primarily used for? Personal or business use?

If applicable, please describe any commercial or business use of your vehicle:

I Agree: that Laroche Mcdonald Insurance is authorized to use my personal information from the Saskatchewan Auto Fund, including my driving history, claims history and insurance history for the purposes of evaluating my entitlement to automobile insurance. I understand that this personal information is necessary to assess the risk, issue the insurance contract, renewal, detect and prevent fraud and investigate and settle any claim. I authorize you to disclose all information Laroche Mcdonald Insurance collects for the purpose of evaluating my entitlement for insurance coverage to all insurance markets dealt with by Laroche Mcdonald Insurance.

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