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" Our clients voted H&K the Tab's Reader's #1 choice for the "Exceptional Business and Professional Service Award" for insurance."


Independent Insurance Agent
H&K Canada Card Request Form

Use this form to request a Canada card for your automobile coverage. Please provide as much information possible so that we can best assist you. This information will be kept confidential and will be used for internal purposes only.

General Information
Insured's Name(s):
Address:
City: State: Zip:
Phone: Fax:Work:
Email Address:
Vehicle you will be driving: Year: Make: Model:
When will you be leaving: Date:


Additional Comments
Please list any additional comments below:


Please click on the "Send" button to send your request.
One of our representatives will respond to your submission as soon as possible.


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