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Vehicle Replacement Form

This form will allow you to send us most of the required information to remove a vehicle on your policy and replace it with an other vehicle. 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.

 

About you

Name(s) of insured(s)
(as named on your policy)   

1st Named Insured:

   

 

2nd Named Insured:

   


Your preferred means of communication for contact and follow-up :
 

E-mail

 

Phone

 


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.

  

Disclaimer

 

E-mail address :

Daytime telephone number :

    Ext.  

Home telephone number :

  


Prior vehicle

Vehicle make :

Year :

Model :


New vehicle

Vehicle make :

Year :

Model :


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 :

Cellular phone
Alarm system
Disabling device
Non-factory installed disabling device
Engraving
Flashing alert light
Tracking system


Have any modifications that are not factory installed been made to the vehicle ?

Yes No

Is there any unrepaired damage ?

Yes No

If Yes, specify :  

Is this vehicle leased or financed?  

If Yes, specify :  

The vehicle is registered
under who's name?


Use of vehicle :  


If other, specify   :


How many kilometres a year does this vehicle travel?


How many kilometres (one way) is this vehicle driven daily to go to work or school ?


If you have more than one vehicle on your policy, will
the replacement of this vehicle result in changes to
the way the remaining vehicle(s) are used ?

 Yes No
 

Driver information

This new vehicle is operated by the following drivers :

Driver Name

Date of birth

 

Type of driver   

(dd / mm / yyyy)

(dd / mm / yyyy)

(dd / mm / yyyy)

Effective date

When will this change be effective ?

 

(dd / mm / yyyy)

About your insurance

Specify the policy to which this change applies:

Company

If other, specify

Insurance policy number


Do you want to change your coverage ?

Yes No

If Yes, specify :  

Is there any other information you want to send us ?

   

 

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