Consumers - Magermans & Raes Insurance Brokers Ltd.

Consumers

Policy Change Forms – Delete Vehicle

* Mandatory Field

About You

Name(s) of insured(s):

1^st insured:*

2^nd insured:

How can we reach you?

E-mail address:*

Daytime telephone #:*

Home telephone #:

Fax #:

Vehicle Information

Vehicle make:

Year:

Model:

If you have more than one vehicle, will the deletion of this vehicle result in changes to the way the remaining vehicles are used?

Yes

No

Effective Date

When will this change be effective?
(dd/mm/yyyy)

About Your Insurance
(Specify the policy to which this change applies)

Company:

Policy #:

Reason for deletion the vehicle:

Additional Comments:

Name of your broker:

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