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 Vehicle Information Vehicle Year: Vehicle Make: Vehicle Model: Use of Vehicle:PleasureCommute (School/Work)BusinessOther Comments (details if use is other): Kilometres travelled per year: How many kilometres one-way for daily commute? Will this vehicle be used for work-related travel (not including travel to and from the workplace)? YesNo If this vehicle is used for work-related travel, how many kilometers/year (not including travel to and from the workplace)? Will adding this vehicle result in changes in use of other vehicles owned? YesNo If yes, specify: Is this vehicle used out of the province more than 30 days/year? YesNo Is this vehicle used for commercial or delivery purposes? YesNo Effective Date: When will this change be effective? About Your Insurance (Specify The Policy To Which This Change Applies) Company: AvivaRSAWA Policy Number: Will this change in use result in changes in use of any other vehicles owned? YesNo If so, please indicate what will change: 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.