Le Groupe Lepelco inc. - Address Change Form

Address Change Form

Vehicle Addition Form

Vehicle Deletion Form

Vehicle Replacement Form

Driver Addition Form

Driver Deletion Form

Change Driver Details Form

Address Change Form This form will allow you to make a change of address to your policies. Make sure you have your current insurance certificate or policy on hand. One of our Customer Service Representatives will review your file and will contact you if your move impacts your insurance policy (for example, the distance you drive to work may have changed or you have a new house to insure). 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:
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

Your preferred means of communication for contact and follow-up :
E-mail
Phone

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

Change your address

Prior address

Number and street :
Apartment no. / P.O. Box No :
City :
Province :
Postal code :

New address

Number and street :
Apartment no. / P.O. Box No :
City :
Province :
Postal code :
Tel. (home) :
Tel. (business) :	Ext. :
New Occupation (if applicable) :
New Email address (if applicable) :

Effective date

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

About your insurance

Specify the policy/policies to which this change applies:

Policy	Company	If other, specify	Type of insurance	Insurance policy number
1
2
3

If the name insured on one of the policies is not your name, please explain:

Is there any other information you want to send us?