Staebler Insurance Brokers - Tools & Resources

The Best Insurance Is An Insurance Broker

Policy Change Forms - Address Change

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 Address

Number and street:

Apartment#/PO Box:

City:

Province:

Postal Code:

New Address

Number and street:

Apartment#/PO Box:

City:

Province:

Postal Code:

Telephone (home):

Telephone (business):

Ext#:

New Occupation (if applicable):

Effective Date

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

Is there any change in use of the vehicle:

Yes

How many Kilometers one-way to work from new address:

About Your Insurance
Specify the policy to which this change applies:

Policy #1

Policy #2

Policy #3

Type of insurance:

Company:

Policy #:

If the name insured on one of the policies is not yours, please explain:

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.