Le Groupe Lepelco inc. - Vehicle Addition Form

Address Change Form

Vehicle Addition Form

Vehicle Deletion Form

Vehicle Replacement Form

Driver Addition Form

Driver Deletion Form

Change Driver Details Form

Vehicle Addition Form This form will allow you to send us most of the required information to make a vehicle addition. It is mainly for personal use vehicles. If you wish to add a recreational vehicle, motorcycle, snowmobile or other, please contact us. 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 :

New Vehicle

Vehicle make :
Year :
Model :
Condition at time of purchase :
Purchase date :		(dd / mm / yyyy)
Purchase price :
VIN (Vehicle identification number) :
Check off each safety, security and communication item that applies to this vehicle :		Cellular phone Alarm system Disabling device Non-factory installed disabling device Engraving Flashing alert light Tracking system

Have any modifications that are not factory installed been made to the vehicle?	Yes No
Is there any unrepaired damage ?	Yes No

If Yes, specify :
Is this vehicle leased or financed?
If Yes, specify the name of the leaser
The vehicle is registered under whose name?

Use of vehicle :
If other, specify :
How many kilometres a year does this vehicle travel?
How many kilometres (one way) is this vehicle driven daily to go to work or school?
Will the addition of this vehicle result in changes to the way the other vehicle(s) are used?	Yes No

Driver information

This new vehicle is operated by the following drivers :

Driver Name	Date of birth		Type of driver
		(dd / mm / yyyy)
		(dd / mm / yyyy)
		(dd / mm / yyyy)

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 ?

Note: If necessary, do not forget to fill the Add a driver Form.