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Policy Change Forms – Replace a Vehicle
About You  
Name(s) of insured(s):  
1st insured:
2nd insured:
How can we reach you?
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:
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:
Comments (details if use is other):
Kilometres traveled per year:
How many kilometers one-way for daily commute?
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:
   
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: