Staebler Insurance Brokers - Tools & Resources

The Best Insurance Is An Insurance Broker

Policy Change Forms - Add 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 #:

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 whether leased or financed:

Names and address of leasing company lien holder:

Use of vehicle:

Comments (details if use is other):

Kilometres traveled per year:

How many kilometers one-way for daily commute?

Will adding this vehicle result in changes in use of other
vehicles owned?

Yes

Third party Liability coverage requested:

Collision coverage and deductible requested:

No Coverage
Yes - deductible
(min) $500	$1000	Higher

Comprehensive coverage and deductible requested:

No Coverage
Yes - deductible
(min) $300	$500	Higher

All perils coverage and deductible requested:

No Coverage
Yes - deductible
(min) $500	$1000	Higher

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:

Disclaimer:

H.L. Staebler Company Limited is not responsible for instructions not received and acknowledged by a confirmation via e-mail or phone call. By submitting this form, you acknowledge that you are the policyholder and the events described on this form are truthful. Only the person named as the insured in the policy documents can submit a claim report on this policy. All policy terms and conditions apply, subject to policy status at time of submission.