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Online Quotes

- Auto Quote

Contact Us:

P: (403) 508-1111 F: (403) 508-1118
holly-gordon
@shawbiz.ca

# 102
1010 8th Ave SW
Calgary, AB
T2P 1J2

Free Automobile Insurance Quote

Welcome to our online Auto Quote system.

To get a no obligation quote, please complete the following form and submit it to our office.
You will be contacted via your chosen method(below), within the next three business days.

Please note:

All fields must be completed for us to give you an accurate quote.

You do not have to complete the entire form again if you want a quote for a different vehicle. Simply fill out the Vehicle 2 information area.

We can only provide insurance for residents of Alberta, Canada.

This form is only required if you are not already a customer of Holly-Gordon Insurance. If you are already insured with us, please go to our Existing Customer Section.

Personal Information * Required

First Name:
Last Name:
Address:
City:
Province:	Postal Code:
Current Employer:
(used to determine if you qualify for group rate)

Contact Information * Required


Home Phone:
Office Phone:	Ext.
Fax:
E-mail:
Contact By:	E-mail Telephone Mail

Insurance Information

Are you an existing client of ours?
	Yes No
	If yes, what type of insurance? Auto Home Both Other
Have you ever had your insurance cancelled or refused?
	Yes No
Do you currently have auto insurance?
	Yes No
Expiry date of existing or last insurance policy (dd/mm/yyyy)

How many years have you had consecutive insurance?

Do you own your own home or condominium?
	Yes No

Drivers Information

	Driver 1	Driver 2	Driver 3
Name:
Age:	yrs old	yrs old	yrs old
Years licensed in Canada:	years	years	years
License Class:
Sex:
Marital status:
Driving school?	Yes No	Yes No	Yes No
Occupation:
Are you a graduate of any post-secondary institution in North America?
	Yes No	Yes No	Yes No

Minor traffic convictions in the past 3 years:
minor violations include speeding, prohibited turn and other similar offences

Major traffic convictions in the past 3 years:
major violations include impaired driving, careless driving, refusing breathalyzer & other similar offences


Have any of the listed drivers had their license suspended or revoked in the past 6 years?
	Yes No

In the past 6 years, have any of the above drivers been involved in a car accident, or have any claims been made to your insurance company?
	Yes No If Yes, please complete Claims Information

Claims Information

		Date of Claim
	Type of Claim:	(mm/yyyy)	Driver Involved:
1.
2.
3.

Vehicle Information

	Vehicle 1	Vehicle 2
Year:
Make:
Model:
Style:
Use:
How many Km do you drive per year:
Who is Primary Driver:
Do you currently own this vehicle?	Yes No	Yes No

Coverages & Deductibles * Required

Liability:
	deductible	deductible
Collision:
	deductible	deductible
Comprehensive:

Do you require any of the following Additional Coverages?
Limited Glass Coverage Loss of Use + Rental car in case of an accident Non-Owned Auto Coverage Waiver of Depreciation Coverage (only available on new vehicles)

Additional Comments

Thank you for taking the time to fill out this form,
Select the "Submit" button below and we will contact within the next 3 business day(s). Our quote will include the coverages you selected plus the standard Accident Benefits coverages.

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