Change Use of Vehicle

Name(s) of insured

1st insured:

2nd insured:

How can we reach you: E-MailPhone

Email:

Daytime Phone:

Home Phone:

Vehicle Information

Make:

Year:

Model:

Use of Vehicle:
PleasureCommutingBusinessFarmingOther

Comments (include details if use is other):

Is this vehicle used out of the province more than 30 days/year?
—Please choose an option—YesNo

Is this vehicle used for commercial or delivery purposes?
—Please choose an option—YesNo

Kilometers traveled per year:
0-50005001-1000010001-1500015001-2000020001-2500025001-3000030001 and over

If this vehicle is used for work-related travel, how many km/year (not including travel to and from workplace):

Effective Date

When will tihs change be effective?

About your Insurance (policy to which this change applies)

Company:

Policy #

Will this change in use result in changes in use other any other vehicles owned? If so, please indicate what will change:

Name of your Broker: