Policy Change

Insured Name*

Policy Number or Binder Number*

Policy Change Effective Date*

Cannot be backdated - Format - dd/mm/yyyy

Policy Change Type*

Please select all types of applicable changes for this policy only. Do not enter changes for different policies on same policy change request. Please create a separate request for each policy.

Vehicle Addition / Deletion
Driver Addition / Deletion
Property Addition / Deletion
Equipment Addition / Deletion
Something Else to be Changed

Vehicle Addition/ Deletion (Add Multiple Vehicles by using "+" sign in right of the box)

Example:- Delete/ Add - Year, Make, Model and VIN, Purchase or Sale Date, ACV | Delete - 2018 Hino 386 1 HSG7856785GBHG986 April 20, 2019, $50,000

Add / Delete / Park	Year Make Model VIN	Actual Cash Value

Loss Payee Name Address and Email (Add Multiple Loss Payees by using "+" sign in right of the box)

Example:-Name of Finance or Lease Company, Address, Email | Bennington Financial Corp. 102-1465 North Service Road East Oakville ON L6H 1A7 Canada joe@benningtonfinance.ca

Finance or Lease Company Name	Address	Email

Driver Addition/ Deletion (Add Multiple Drivers by using "+" sign in right of the box)

Example:- Delete/ Add - Name, Date of Birth, License Number, Years of Experience | Add Tom Gates 28 Oct 1986 DL# - 166543- 982, 2.5 Yrs

Full Name	Date of Birth and License Number	Years of Experience

Property Addition/ Deletion (Add Multiple Properties by using "+" sign in right of the box)

Example:- Address - 4112 30 St NW, Edmonton, AB, T6T 1K5, Value - Building - $ 500K and Content $300K, Year Built - 1999, Type of Fire Protection - Fire Hydrants and Extinguishers

Equipment Addition/ Deletion (Add Multiple Equipment by using "+" sign in right of the box)

Example:- Year - 2004, Make - BOB CAT, Model - 65R, Serial Number - 654FG32 Value - $ 58000

Describe the policy change you need

Please include as much information as you can and attach relevant documents later.

Name of Person Requesting Policy Change*

First Last

Email

Phone

Upload all the documents related to this policy change

Example : Bill of Sale, Drivers Abstract, Registration, Old Pink Card etc.

Drop files here or

Max. file size: 5 MB, Max. files: 10.

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Policy Change

Requesting a policy change does not confirm a policy change, it will be confirmed by separate communication