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After reporting a claim you will be contacted by one of our Brokers to confirm we have received your information and to obtain additional information that may be required or for immediate help you may call our emergency toll free number 1-888-727-7911.

About You
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(dd/mm/yy):
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:
Names and address of leasing company lien holder:
Use of vehicle:	Pleasure Commuting Business Farming Other
Comments (details if use is other):	Leased Financed
Kilometres 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 vehicles owned?	Yes     No
Third party Liability coverage requested:	$1,000,000 $2,000,000
Collision coverage and deductible requested:	$50 $100 $200 $350 $500
Comprehensive coverage and deductible requested:	$50 $100 $200 $350 $500
All perils coverage and deductible requested:	$50 $100 $200 $350 $500
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:	Principal Occasional Principal Occasional Principal Occasional
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: