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Policy Change Forms – Add Vehicle
* Mandatory Field
About You  
Name(s) of insured(s):  
1st insured:*
2nd insured:
How can we reach you?
E-mail address:*
Daytime telephone #:*
Home telephone #:
Fax #:
   
New Vehicle  
Vehicle make:
Year:
Model:
Condition at time of purchase:
Purchase date(dd/mm/yy):
Purchase price:
VIN (vehicle ID #):
   
Any non-factory modifications to the vehicle?
Yes     No
Any unrepaired damage?
Yes     No
If yes, specify:
Is vehicle leased or financed?
Yes     No
If yes, specify whether leased or financed:
Names and address of leasing company lien holder:
Use of vehicle:
Comments (details if use is other):
Kilometres traveled per year:
How many kilometers one-way for daily commute?
Will adding this vehicle result in changes in use of other
vehicles owned?
Yes     No
Third party Liability coverage requested:
Collision coverage and deductible requested:
No Coverage
Yes - deductible
(min) $500  $1000  Higher
Comprehensive coverage and deductible requested:
No Coverage
Yes - deductible
(min) $300  $500  Higher
All perils coverage and deductible requested:
No Coverage
Yes - deductible
(min) $500  $1000  Higher
   
Driver Information  
(for all drivers who will be operating this vehicle)
Driver #1 Driver #2 Driver #3
Driver:
Date of birth (dd/mm/yyyy):
Driver type:
   
Effective Date  
When will this change be effective? (dd/mm/yyyy):
   
About Your Insurance
(Specify the policy to which this change applies) 		 
Company:
Policy #:
Additional Comments:
Name of your broker:
   
 

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