Vehicle Addition Form

This form will allow you to send us most of the required information to make a vehicle addition. It is mainly for personal use vehicles. If you wish to add a recreational vehicle, motorcycle, snowmobile or other, please contact us.

For your added protection, any change you make to your policy does not become effective until we contact you to verify the change and effective date. This is to protect your existing coverage, should additional information or coverage be required to make the change you have asked.

About you

Name(s) of insured(s)
(as named on your policy)   

1 ^st Named Insured:

2 ^nd Named Insured:

Your preferred means of communication for contact and follow-up :
 

E-mail

Phone

We can only accept changes from policyholders.
Please check this authorization box, before completing the rest of the form :
 

 I'm the owner of the policy and I'm authorized to submit these changes.

Disclaimer

E-mail address :

Daytime telephone number :

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905       ext. : 

Home telephone number :

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905   

Vehicle make :

Year :

Model :

Condition at time of purchase :  

Select New Demo Used

Purchase date :

  (dd / mm / yyyy)

Purchase price :

VIN (Vehicle identification number) :  

Check off each safety, security and communication item
that applies to this vehicle :

Cellular phone
Alarm system
Disabling device
Non-factory installed disabling device
Engraving
Flashing alert light
Tracking system

Have any modifications that are not factory installed been made to the vehicle?

Yes No

Is there any unrepaired damage ?

Yes No

If Yes, specify :  

Is this vehicle leased or financed?  

Select None Car loan Lease

If Yes, specify the name of the leaser 

The vehicle is registered under whose name?  

Use of vehicle :  

Select Pleasure (no commuting) Commuting to work or school Business Farming Other

If other, specify :  

How many kilometres a year does this vehicle travel?

Select 0 to 5 000 5 001 to 10 000 10 001 to 15 000 15 001 to 20 000 20 001 to 25 000 25 001 to 30 000 30 001 or more

How many kilometres (one way) is this vehicle driven daily to go to work or school?

Select 0 less than 9 9 to 16 17 to 24 25 to 34 35 to 50 more than 50

Will the addition of this vehicle result in changes to the way the other vehicle(s) are used?

Yes No

Driver Name

Date of birth

Type of driver

(dd / mm / yyyy)

Select Principal Occasional

(dd / mm / yyyy)

Select Principal Occasional

(dd / mm / yyyy)

Select Principal Occasional

When will this change be effective?  

(dd / mm / yyyy)

Company

If other, specify

Insurance policy number

Select ING Insurance ING Novex ING Western Union Other