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Add Vehicle
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:
Overview
Web Links
Insurance Tips
Glossary Of Terms
Policy Change Forms
Address Change
Replace Vehicle
Add Vehicle
Delete Vehicle
Change Use of Vehicle
Claims
CISRO Principles of Conduct
RIBO Broker Fact Sheet