Replace Vehicle

Name(s) of insured(s)
1st insured:
2nd insured:
How can we reach you:
E-mail Address:
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:	YesNo
Any unrepaired damage:	YesNo
If yes, specify:
Is vehicle leased or financed:	NoLeasedFinanced
Names and address of leasing company lien holder:
Use of Vehicle:
Comments (details if use is other):
Kilometers traveled per year:
How many kilometers one-way for daily commute:
Will adding this vehicle result in changes in use of other:	Yes No
Third party Liability coverage requested:
Collision coverage and deductible requested:	None$500$1000Higher
If Higher, please specify:
Comprehensive coverage and deductible requested:	None $300 $500 Higher
If higher, please specify:
All perils coverage and deductible requested:	None $500 $1000 Higher
If higher, please specify:
Driver #1
Driver:
Date of Birth:
Driver type:
Driver #2
Driver:
Date of Birth:
Driver type:
Driver #3
Driver:
Date of Birth:
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:

2675 Hamilton Rd.
Box 280 (Brights Grove)
Sarnia, Ontario, N0N 1C0

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