Main Office

431 Huronia Road, Unit 11
Barrie, ON L4N 9B3
Phone: 705-721-4755
Toll Free: 1-800-461-4286
Fax: 705-721-5021

Hours: Monday to Friday
8:30am to 5:00pm

High Risk Auto Insurance

88 Essa Rd.
Barrie, ON L4N 3K7
Phone: 705-728-6909
Fax: 705-735-6831
Web: www.highriskdrivers.ca

Hours: Monday to Thursday
9:00am to 5:00pm
Friday 9:00am to 4:00pm

Auto Insurance Quote Request

Personal Information:
First Name:
Last Name:
Gender:	Male Female
Address:
City:
Province:
Postal Code:
Contact Number:
Fax Number:
Email Address:
Date of Birth:
Month/Year G1, G2 or G license aquired:
G1:
G2:
G:
Marital Status:
Do you own a home or rent?OwnRent
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 Questions:
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 preferences:
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