Tools and Resources

Policy Change Forms - Replace Vehicle

About You
Name(s) of insured(s):
1st insured:
2nd insured:
How can we reach you?	E-Mail Phone
E-mail address:
Daytime telephone #:
Home telephone #:
Fax #:
Prior Vehicle
Vehicle make:
Year:
Model:
New Vehicle
Vehicle make:
Year:
Model:
Condition at time of purchase:	New Demo Used
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:
Name of registrant:
Use of vehicle:	Pleasure Commuting Business Farming Other
Comments (details if use is other):
Kilometres traveled per year:	0-5000 5001-10000 10001-15000 15001-20000 20001-25000 25001-30000 30001-over
How many kilometers one-way for daily commute?	N/A 0-5 6-8 9-16 17-24 25+
Will replacing this vehicle result in changes in use of other vehicles owned?	Yes     No
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:	Principal Occasional Principal Occasional Principal Occasional
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: