Tools & Resources - Bickerton Brokers Ltd

Tools & Resources

Policy Change Forms - Replace Vehicle

About You

Name(s) of insured(s):

1^st insured:

2^nd 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 (dd/mm/yy):

Purchase price:

VIN (vehicle ID #):

Any non-factory modifications to the vehicle?

Yes

Any unrepaired damage?

Yes

If yes, specify:

Is vehicle leased or financed?

Yes

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

Driver Information

(for all drivers who will be operating this vehicle)

Driver #1

Driver #2

Driver #3

Driver:

Date of birth (dd/mm/yyyy):

Driver type:

Effective Date

When will this change be effective? (dd/mm/yyyy)

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

Company:

Policy #:

Additional Comments:

Name of your broker: