Policy Change Forms – Change Use of Vehicle

*(denotes required field)

E-Mail Address:

--- About You ---
Name(s) of insured(s):

1st insured:

2nd insured:

How can we reach you?

Daytime telephone #:

Home telephone #:

Fax #:

--- Vehicle Information ---

Vehicle Make:

Year:

Model:

Use of vehicle:

Comments (details if use is other):

Is this vehicle used out of the province more than 30 days/year?

Yes No

Is this vehicle used for commercial or delivery purposes?

Yes No

Kilometres traveled per year:

How many kilometers one-way for daily commute?

If this vehicle is used for work-related travel, how many kilometers/year (not including travel to and from the workplace)?

--- Effective Date ---

When will this change be effective?

--- About Your Insurance ---
(Specify the policy to which this change applies)

Company:

Policy #:

Will this change in use result in changes in use of any other vehicles owned?

Yes No

If so, please indicate what will change:

Name of your broker:

CAPTCHA Code: *

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