Le Groupe Lepelco inc. - Driver Addition Form

Address Change Form

Vehicle Addition Form

Vehicle Deletion Form

Vehicle Replacement Form

Driver Addition Form

Driver Deletion Form

Change Driver Details Form

Driver Addition Form 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.

About you
Name(s) of insured(s) (as named on your policy)	1^st Named Insured:
	2^nd Named Insured:
Your preferred means of communication for contact and follow-up :
E-mail
Phone
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.
Disclaimer

E-mail address :
Daytime telephone number :	ext. :
Home telephone number :

Driver information

Driver's First Name :
The initial of the middle name :
Last Name :
Date of birth :	(dd / mm / yyyy)
Gender :	Male Female
Marital status :
Relationship to the insured :
Driver licence number :

What class of licence does this driver hold ?
Number of years with a valid driver's licence :
Province or country where driver's licence issued :

Has this driver ever had their driver's licence suspended or cancelled in the last 3 years ?	Yes No
Has this driver taken and passed an official and recognized driver training course ?	Yes No
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 ?	Yes No

If yes, please provide the details below :
1. Year:
2. Year:
3. Year:

Has the driver had any traffic violations in the last 3 years ? (Do not include parking violations.)	Yes No
If yes, specify :
How many MINOR traffic violations has this driver had in the last 3 years ?
How many MAJOR traffic violations has this driver had in the last 3 years ?

Vehicle information

This new driver operates the following vehicle(s) :
Vehicle	Make	Year	Model	Type of driver
1
2
3

Effective date

When will this change be effective ?
	(dd / mm / yyyy)

About your insurance

Specify the policy to which this change applies :

Company	If other, specify	Insurance policy number

Is there any other information you want to send us ?