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.
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 :
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?
The vehicle is registered
under who's 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 and 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
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 ?
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
Do you want to change your coverage ?
Is there any other information you want to send us ?