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Name(s) of insured(s)
1st insured:
2nd insured:
How can we reach you:
E-Mail
Phone
E-mail address:
Daytime telephone #:
Home telephone #:
Fax #:
New Vehicle
Vehicle make:
Year:
Model:
Condition at time of purchase:
New
Demo
Used
Purchase Date:
Date and time
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 whether leased or financed:
Leased
Financed
Names and address of leasing company lien holder:
Use of Vehicle:
Pleasure
Commuting
Business
Farming
Other
Comments (details if use is other):
Kilometers traveled per year:
0-5000
5001-10000
10001-15000
15001-20000
20001-25000
25001-30000
30001-over
How many kilometers one-way for daily commute:
N/A
0-5
6-8
9-16
17-24
25+
Will adding this vehicle result in changes in use of other:
Yes
No
Third party Liability coverage requested:
$1,000,000
$2,000,000
Collision coverage and deductible requested:
none
$500
$1000
Higher
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:
Date and time
Driver type:
Principal
Occasional
Driver #2
Driver:
Date of Birth:
Date and time
Driver type:
Principal
Occasional
Driver #3
Driver:
Date of Birth:
Date and time
Driver type:
Principal
Occasional
Effective Date
When will this change be effective:
Date and time
Now
About Your Insurance (Specify the policy to which this change applies)
Company:
Policy #:
Additional Comments:
Name of your broker:
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