Who?
Our Values
Our Team
Trusted Partners
What?
Claims Concierge
Home
Auto
Commercial
Farm
Umbrella
Where?
Contact Us
Client Login
HGA Group
Accounting & Tax
Wealth
Law
Consulting
Marketing
Auto Insurance Quote
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 10
Let's get started.
What type of insurance are you looking for?
Home
Auto
Home + Auto
Next
First, a bit about you...
We'd like to collect some basic information.
Primary Phone
Primary E-mail
Primary Contact Person
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Preferred Contact Method:
Phone
E-mail
Next
Drivers
Tell us about the Drivers in your household.
First Name
Last Name
Birth Date
Gender
Male
Female
Other
Drivers Licence Number
Date Licenced
Driving History
Tell us about this driver's history:
How many tickets has this driver had in the last 3 years?
0
1
2
3
4
5+
Ticket 1: What was it for?
Ticket 1: When did it happen?
Ticket 2: What was it for?
Ticket 2: When did it happen?
Ticket 3: What was it for?
Ticket 3: When did it happen?
Ticket 4: What was it for?
Ticket 4: When did it happen?
Sorry...
We won't be able to process this online - please give us a call to discuss!
How many suspensions has this driver had in the past 6 years?
0
1
2
3
4+
Suspension 1: What was it for?
Suspension 1: When was it?
Suspension 2: What was it for?
Suspension 2: When was it?
Suspension 3: What was it for?
Suspension 3: When was it?
Sorry...
We won't be able to process this online - please give us a call to discuss!
How many at-fault accidents has this driver had in the past 10 years?
0
1
2
3
4+
Accident 1: When did it happen?
Accident 1: Please share details of the accident.
Accident 2: When did it happen?
Accident 2: Please share details of the accident.
Accident 3: When did it happen?
Accident 3: Please share details of the accident.
Sorry...
We won't be able to process this online - please give us a call to discuss!
Next
Would you like to add another driver?
Yes
No
Next
Driver
Tell us about the second driver in your household.
First Name
Last Name
Birth Date
Gender
Male
Female
Other
Drivers Licence Number
Date Licenced
Driving History
Tell us about this driver's history:
How many tickets has this driver had in the last 3 years?
0
1
2
3
4
5+
Ticket 1: What was it for?
Ticket 1: When did it happen?
Ticket 2: What was it for?
Ticket 2: When did it happen?
Ticket 3: What was it for?
Ticket 3: When did it happen?
Ticket 4: What was it for?
Ticket 4: When did it happen?
Sorry...
We won't be able to process this online - please give us a call to discuss!
How many suspensions has this driver had in the past 6 years?
0
1
2
3
4+
Suspension 1: What was it for?
Suspension 1: When was it?
Suspension 2: What was it for?
Suspension 2: When was it?
Suspension 3: What was it for?
Suspension 3: When was it?
Sorry...
We won't be able to process this online - please give us a call to discuss!
How many at-fault accidents has this driver had in the past 10 years?
0
1
2
3
4+
Accident 1: When did it happen?
Accident 1: Please share details of the accident.
Accident 2: When did it happen?
Accident 2: Please share details of the accident.
Accident 3: When did it happen?
Accident 3: Please share details of the accident.
Sorry...
We won't be able to process this online - please give us a call to discuss!
Next
Would you like to add another driver?
Yes THIS PART ISNT MADE YET
No
Next
Tell us about your vehicles.
Let's get some information on your vehicles!
Year
Make
Model
VIN #
Main Driver
Owner(s)
Type of Vehicle
Car
Truck
Van
ATV
Motorcycle
Utility Trailer
Travel Trailer
Motorhome
Use
Personal Only
Commute
Business
Number of KMs on Commute (One Way)
Less than 10kms
10-20kms
21-30kms
30+ kms
Average Annual Kilometers
Next
Coverage Information
Do you have liability?
Yes
No
What is the limit?
Do you have collision?
Yes
No
What is the deductible?
Do you have comprehensive?
Yes
No
What is the deductible?
Optional endorsements:
Glass Limitation
Accident Forgiveness
Conviction Forgiveness
Depreciation Waiver
Replacement Cost
Transportation Replacement
Nonowned Vehicle Extension
Emergency Services
Next
Would you like to add another vehicle?
Yes THIS PART ISNT MADE YET
No
Next
Thank you!
We appreciate you taking the time to fill out this information. We will be in touch shortly!
I agree to the terms and conditions of this website to store and hold my data.
*
I agree
Submit
