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Auto Insurance
Home & Property Coverage
Homeowner Insurance
Condo Insurance
Renter & Tenant Insurance
Business
Edmonton Business Insurance
Professional Services Insurance
Trades & Industrial Insurance
Retail & Service Industry Insurance
Claims
Claims
Report a Claim
24/7 Emergency Claim Contacts
About
About Us
Careers
Our Partners
Blog
Contact
Contact Us
Edmonton South Branch (Windermere)
Edmonton North Branch
St. Albert Branch
Jasper Branch
Get a Quote
Policy Change Request – Auto – Add or Sub Vehicle
1
Contact Info
2
Vehicle Info
Assigned Broker
*
Boaz Lau
Diana Rao
Edianor Carneiro
Eric Yang
Guest Account
Jack Rao
Jackie Brundell
Jean-Marie Hannaford
Justin Chau
Katherine Tan
Kristy Tsang
Mackenzie Bell
Megan Gaines
Miteesh Grover
Nick Zhong
Paul Nam
Sunny Leung
Teddy Ng
Tyson Lush
Hidden
Assigned Broker
Any Available Broker
Jackie Brundell
Justin Chau
Jack Rao
Kelvin Ho
Megan Gaines
Tyson Lush
Policy number
*
Policyholder(s)
*
Is there another name on the vehicle title or registration that is not currently a Policyholder?
Yes
No
Name of additional policyholder to be added:
*
Email
Best primary contact number
Please verify current address
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Effective date to add new vehicle
MM slash DD slash YYYY
Effective Time
:
Hours
Minutes
AM
PM
AM/PM
Are you removing an existing vehicle and substituting the new vehicle on to the policy?
*
Yes
No
Hidden
Old vehicle info
Confirm year/make/model of vehicle to be removed:
*
Effective date to delete old vehicle
MM slash DD slash YYYY
Effective time to delete old vehicle
:
Hours
Minutes
AM
PM
AM/PM
New vehicle info
Please type in the year, make model of the new vehicle:
*
VIN (serial number):
Is the vehicle brand new, demo, or used?
Brand new
Demo
Used
If vehicle is a demo, enter kms on odometer:
*
Purchase date (from bill of sale):
MM slash DD slash YYYY
Purchase price:
Is the vehicle financed, leased, or a cash sale?
Financed
Leased
Cash Sale
Name of financing company or lessor:
Mailing address of financing company or lessor:
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Is this vehicle a salvage vehicle?
Yes
No
Is there a copy of the completed salvage inspection present? This must be obtained along with u/w approval to submit the change.
*
Yes
Is there any damage to this vehicle?
Yes
No
Please provide a description of existing damage, and send a photograph of the damage at the earliest opportunity:
Are there any performance modifications or attachments to the vehicle?
Yes
No
Please provide a description and value of the modifications/attachments.
Coverage info
Liability coverage:
Keep same as existing policy
1 million
2 million (recommended)
Would like more than 2 million
As the costs of bodily injury lawsuits continue to rise, our latest brokerage recommendation is that clients carry at least 2 million liability coverage for auto insurance. The cost increase is fairly low for most clients (about 5%-10%). A personal umbrella policy is also available for higher limits than 2 million.
Collision deductible:
Do not want collision coverage
$500 deductible (most popular)
$1,000 deductible
Fire & theft deductible:
Do not want fire & theft coverage
$250
$500 (most popular)
$1000
Would you like to add all perils glass coverage (approx $300/year)?
Please choose
Please choose
No, do not want glass coverage
Yes
Examples of perils that are not covered on a standard auto policy: rock chips to glass, vandalism to the front windshield, shattered glass due to temperature change.
Usage info
Primary operator of this vehicle:
Occasional operators of this vehicle:
If there are occasional operators that are already listed as primary operators on other vehicles on the policy, you do NOT need to list them here.
Are there any other people in the household with a driver license that are not already listed above or elsewhere on the policy?
*
Yes
No
Please note that all drivers living in the household must be disclosed, regardless of whether they have access to your vehicle or not.
Provide details for the other drivers in the household:
Daily commute (one-way):
Please choose
0 km; recreational use only
3 km or less
4-5 km
6-7 km
8-10 km
11-12 km
13-15 km
16-20 km
21-25 km
26-30 km
31-35 km
Over 35 km
Estimated total annual distance:
Please choose
5,000 KM or less
8,000 KM
10,000 KM
12,000 KM
15,000 KM
20,000 KM
25,000 KM
30,000 KM or more
Is this vehicle used for any business or commercial use, such as making deliveries, drive for hire (ex: Uber), or to carry any tools or materials for a trade or work purposes?
*
Yes, some business or commercial use
No business or commercial use whatsoever
About how many business kms is this vehicle driven each year?
Please choose
5,000 KM or less
8,000 KM
10,000 KM
12,000 KM
15,000 KM
20,000 KM
25,000 KM
30,000 KM or more
Please provide a summary of exactly how the vehicle is being used and/or what is being carried:
*
Please note:
this form is for streamlining the process of collecting information only. No changes will be made until a broker has reviewed and confirmed the potential changes with you. If you require a time-sensitive change to your insurance policy, please call our office immediately.
By clicking "I agree", I consent and authorize my broker, agent or insurer to collect, use and disclose to appropriate third parties personal information as permitted by law for the purposes necessary to quote risks, investigate and settle claims, and detect and prevent insurance fraud, such as credit information, driving record information, and claims history.
Consent:
*
I agree
Δ
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