the confidentiality of your informations is important to us
This form will allow you to send us most of the required information to make a vehicle addition. It is mainly for personal use vehicles. If you wish to add a recreational vehicle, motorcycle, snowmobile or other, please contact us.
For your added protection, any change you make to your policy does not become effective until we contact you to verify the change and effective date. This is to protect your existing coverage, should additional information or coverage be required to make the change you have asked.
Name(s) of insured(s)
(as named on your policy)
1 st Named Insured:
2 nd Named Insured:
Your preferred means of communication for contact and follow-up :
We can only accept changes from policyholders.
Please check this authorization box, before completing the rest of the form :
I'm the owner of the policy and I'm authorized to submit these changes.
E-mail address :
Daytime telephone number :
Home telephone number :
Vehicle make :
Condition at time of purchase :
Purchase date :
(dd / mm / yyyy)
Purchase price :
VIN (Vehicle identification number) :
Check off each safety, security and communication item
that applies to this vehicle :
Non-factory installed disabling device
Flashing alert light
Have any modifications that are not factory installed been made to the vehicle?
Is there any unrepaired damage ?
If Yes, specify :
Is this vehicle leased or financed?
If Yes, specify the name of the leaser
The vehicle is registered under whose name?
Use of vehicle :
Pleasure (no commuting)
Commuting to work or school
If other, specify :
How many kilometres a year does this vehicle travel?
0 to 5 000
5 001 to 10 000
10 001 to 15 000
15 001 to 20 000
20 001 to 25 000
25 001 to 30 000
30 001 or more
How many kilometres (one way) is this vehicle driven daily to go to work or school?
less than 9
9 to 16
17 to 24
25 to 34
35 to 50
more than 50
Will the addition of this vehicle result in changes to the way the other vehicle(s) are used?
This new vehicle is operated by the following drivers :
Date of birth
Type of driver
(dd / mm / yyyy)
When will this change be effective?
Specify the policy to which this change applies :
If other, specify
Insurance policy number
ING Western Union
Is there any other information you want to send us ?
Note: If necessary, do not forget to fill the Add a driver Form.