This form will allow you to send us the required information to add a new driver to a passenger vehicle on your policy.
Make sure to have your current insurance certificate or policy on hand.
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.
Name(s) of insured(s)
(as named on your policy)
1st Named Insured:
2nd Named Insured:
Your preferred means of communication for contact and follow-up :
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.
E-mail address :
Daytime telephone number :
Home telephone number :
Driver's First Name :
The initial of the middle name :
Last Name :
Date of birth :
(dd / mm / yyyy)
Marital status :
Relationship to the insured :
Sister or brother
Mother or Father
Driver licence number :
What class of licence does this driver hold ?
Number of years with a valid driver's licence :
Less than 1
More than 6
Province or country where driver's licence issued :
North West Territories
Without driving licence
Has this driver ever had their driver's licence suspended or cancelled in the last 3 years ?
Has this driver taken and passed an official and recognized driver training course ?
Has the driver been involved in a motor vehicle accident or presented any other type of auto insurance claim to an insurance company in the last 6 years ?
If yes, please provide the details below :
Less than $1 000
$1 001 to $5 000
$5 001 to $10 000
$10 001 or more
Nature of claim
At-fault accident for 50%
Hit and run
Fire - theft - vandalism
Windstorm or hail
Has the driver had any traffic violations in the last 3 years ?
(Do not include parking violations.)
If yes, specify :
How many MINOR traffic violations has this driver had in the last 3 years ?
5 or more
How many MAJOR traffic violations has this driver had in the last 3 years ?
This new driver operates the following vehicle(s) :
Type of driver
When will this change be effective ?
(dd / mm / yyyy)
Specify the policy to which this change applies :
If other, specify
Insurance policy number
ING Western Union
Is there any other information you want to send us ?
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