Policy Change Forms – Replace Vehicle | Zehr Insurance Brokers Ltd.

Policy Change Forms – Replace 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 #:

--- Prior Vehicle ---

Vehicle Make:

Year:

Model:

--- New Vehicle ---

Vehicle make:

Year:

Model:

Condition at time of purchase:

Purchase Date:

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:

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:

Date of birth:

Driver type:

--- Driver #2 ---

Driver:

Date of birth:

Driver type:

--- Driver #3 ---

Driver:

Date of birth:

Driver type:

--- Effective Date ---

When will this change be effective?

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

Company:

Policy #:

Additional Comments:

Name of your broker:

CAPTCHA Code: *

In this section

What's New

Policy Change Forms – Replace Vehicle

Search this site

News Categories

Archives

Quick Links