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Welcome to Holman Insurance Brokers on-line Personal Automobile Insurance quick quote page. Please ensure you complete the form as accurately as possible in order to ensure the best possible estimate. If you would rather speak to one of our sales representatives, please call us at (905) 886-5630 or 1-800-567-1279.

Completion of this form is for informational purposes only, and is just an estimate.
This WILL NOT result in a new policy, or change to an existing policy.

* Required Fields , Click on for an explanation (where appropriate)                                              
Contact Information
First Name*
Last Name*
Address*
City*
Province*
Postal Code*
Phone*
Phone 2
E-Mail*
Contact Method
Phone Email
Insurance Information
Are you presently insured? If yes, what company?* (enter "none" if answer is no)
Policy Number* (enter "none" if you do not have a policy number)
Expiry Date
What is your current annual premium?
$
Why are you looking for a new insurer or broker?
Other Information
How many years have you been insured in Canada / US without interruption?*
Has your insurance been cancelled in the past 3 years for non payment?*
Yes No
Vehicle Information (Please call for a quote on more than 4 vehicles)
Information
Vehicle 1
Vehicle 2
Year*
Make*
Model*
Style*
Anti Theft Protection
Yes No
Yes No
Airbags
Yes No
Yes No
Etched Car
Yes No
Yes No
Is the vehicle driven to work?*
Yes No
Yes No
If yes, how far one way? (km)
Vehicle Use*
Annual kilometers*
Driver Information (Please call for a quote on more than 4 drivers)
Information
Driver 1
Driver 2
Driver 3
Name*
Gender*
M F
M F
M F
Marital Status *
Date of Birth*
Date First Lisensed in Canada*
License Info*
License
Class 		Date Licensed
License Class
Date Licensed
License Class
Date Licensed
Day Month Year Day Month Year Day Month Year
G G G
G1 G1 G1
G2 G2 G2
Principal Driver*
Yes No
Yes No
Yes No
Driver Training
Yes No
Yes No
Yes No
Mandatory Coverages
Coverage
Vehicle 1
Vehicle 2
Third Party Liability
Accident Benefits (see below for optional increase)
standard
standard
Uninsured Automobile Coverage
included
included
Direct Compensation Property Damage - Deductible
Optional Coverages (Select from any of the desired coverages below)
Coverage
Vehicle 1
Vehicle 2
Collision (choose deductible)
Comprehensive (choose deductible)
OPCF 19a - Agreed Value of Automobiles
OPCF 20 - Loss of Use
OPCF 27 - Rental Liability