Sutherland Insurance Guelph - Guelph Insurance Policy

name(s) of insured(s):

1^st insured: 2^nd 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 whether leased or financed: 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:

Replace a Vehicle