Change Use of Vehicle

DISCLAIMER: No binder, insurance policy, change, addition, and/or deletion to insurance coverage will go into effect unless and until it is confirmed directly with one of our licensed brokers.

Name(s) of insured(s)
1st insured:
2nd insured:
How can we reach you:
E-mail address:
Daytime telephone #:
Home telephone:
Fax #:
Vehicle Information
Vehicle make:
Year:
Model:
Use of vehicle:
Comments (detials if use is other):
Is this vehicle used out of the province more than 30 days/year:	YesNo
Is this vehicle used for commercial or delivery purposes:	YesNo
Kilometers 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 date be effective:	Date and time
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? If so, please indicate what will change:
Name of your broker:

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