Auto and High Risk Car Quote
House Insurance Quote
Home and Auto Insurance
Home and Auto Insurance
The Insurance Brokers Association of Ontario
Automotive Insurance Quote

Owning a vehicle is a big step to take in life, one that comes with careful thought and planning. Huronia Insurance helps eliminate some of that planning because we are partnered with several outstanding companies, offering you the best auto insurance available.
Personal Information
First Name:
Last Name:
Gender: male female
Postal Address:
Province / State:
Postal Code:
Phone:
Fax:
Email Address:
Date of Birth:
Drivers Licence No:
Marital Status:
Do you own a home or rent? Own Rent
When did you acquire your G1 license?
When did you acquire your G2 license?
When did you acquire your G license?

Vehicle Information
Vehicle Make:
Year Built:
Vehicle Model:
Series Initials: e.g. LE or LX
# of Doors?
2 or 4 Wheel Drive?
VIN#
If Pickup, extended or normal cab?

Additional Qquestions
Have you ever been insured? Yes No
When were you last insured?
  If yes, please state the details and date below:
Are there any other licensed drivers in the household? Yes No
  If yes, please state the details and date below:
Has anyone in the household been suspended in past six years? Yes No
  If yes, please state the details and date below:
Are there any other drivers in the household who do not have current insurance? Yes No
  If yes, please state the details and date below:
Is the vehicle modified or damaged in any way? Yes No
  If yes, please state the details and date below:
Do you currently have auto insurance? Yes No
Who are you currently insured with?
When does your current insurance expire?
Has your insurance recently lapsed? Yes No
  If yes, please state the details and date below:
Has your insurance been cancelled in the last 6 years? Yes No
  If yes, please state the details and date below:
Coverage Desired:
Have you taken a driver safety course? Yes No
Any driving convictions in the past 3 years? Yes No
  If yes, please state for each item the details and date below:
Any suspensions in the past 6 years? Yes No
  If yes, please state for each suspension the details and date below:
Any accidents or claims in the past 6 years? Yes No
  If yes, please state for each accidents (incident) the details and date below:
Do you drive to work? Yes No
  If yes, # of KM driven 1 way:
Postal code of city of employment:
What is the primary use?
How many km a year do you drive?
Rate your own Credit:

Contact Information
When would you like to be contacted? Morning Afternoon Evening Anytime
Any Questions or Comments?
Would you like to receive relevant information from Huronia Insurance Group? Yes No

Please submit the form for each additional vehicle or driver.
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