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?
Any unrepaired damage?
If yes, specify:
Is vehicle leased or financed?
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?
   
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: