Please use this form to request changes:

Name of Insured on Policy
Policy Number
1st Insured
Daytime Telephone

2nd Insured
Home Telephone

Any Other Drivers in Household
Any Other Drivers in Household

 

New Vehicle
Vehicle Year:
Vehicle Make:

Vehicle Model:
VIN #:

Please upload the Bill of Sale, lease agreements, safety, or photos.

Condition at time of purchase:

Purchase date:

Purchase price:

Any non-factory modifications to the vehicle?

If yes, explain:


Any unrepaired damage?

If yes, specify:


Is vehicle leased or financed?

If yes, specify whether leased or financed:

Names and address of leasing company lien holder:

Name of Registrant:


Use of Vehicle:

Comments (details if use is other):


Kilometres travelled per year:

How many kilometres one-way for daily commute?

Will adding this vehicle result in changes in use of other vehicles owned?

If yes, specify:


Third party Liability coverage requested:

Collision coverage and deductible requested:

Yes – Deductible:


Comprehensive coverage and deductible requested:

Yes – Deductible:


All perils coverage and deductible requested:

Yes – Deductible:

 

Drivers Information (For all drivers who will be operating this vehicle):
Driver 1 Name:
Date of Birth:

Driver Type:

 
Driver 2 Name:
Date of Birth:

Driver Type:

 
Driver 3 Name:
Date of Birth:

Driver Type:

 

Effective Date:
When will this change be effective?

 

About Your Insurance (Specify The Policy To Which This Change Applies)
Company:

Policy Number:

Additional Comments:

 
I hereby confirm I am the named insured of this policy and as such take full responsibility that the information I am sending is accurate and truthful.