Policy Change Request: Auto - Add Vehicle - Capital Insurance Brokers

Form Completion*

Broker
Client

Choose "Broker" if the broker is filling out the form on behalf of the client.
Choose "Client" to email this form to the client for completion.

Assigned Broker*

Brokerage Name

Brokerage Address

Policy number*

Insurance Carrier*

Policyholder(s)*

Is there another name on the vehicle title or registration that is not currently a Policyholder?*

Yes
No

Name of additional policyholder to be added:*

Email*

The temporary insurance slip will be sent to this email.

Best primary contact number*

Please verify current address*

Effective date to add new vehicle*

Effective Time

:

Are you removing an existing vehicle and substituting the new vehicle on to the policy?*

Yes
No

This field is hidden when viewing the form

Old vehicle info

Confirm year, make and model of vehicle to be removed*

Effective date to delete old vehicle*

Effective time to delete old vehicle

:

New vehicle info

Type in year, make model of the new vehicle*

VIN (serial number) of new vehicle*

Is the vehicle brand new, demo, or used?*

Brand new
Demo
Used

If vehicle is a demo unit purchased from the dealership, enter kms on odometer:*

Purchase date (from bill of sale):*

Purchase price:*

Is the vehicle financed, leased, or a cash sale?*

Financed
Leased
Cash Sale

Name of financing company or lessor*

Mailing address of financing company or lessor*

Address City Province Postal Code

Is this vehicle a salvage vehicle?*

Yes
No

Is there a copy of the completed salvage inspection present? This must be obtained along with u/w approval to submit the change.*

Yes
No

Is there any damage to this vehicle?*

Yes
No

Please provide a description of existing damage, and send a photograph of the damage at the earliest opportunity:*

Are there any performance modifications or attachments to the vehicle?*

Yes
No

Please provide a description and value of the modifications/attachments.*

Coverage info

Third Party Liability coverage*

1 million
2 million (recommended)

As the costs of bodily injury lawsuits continue to rise, our latest brokerage recommendation is that clients carry at least 2 million liability coverage for auto insurance. The cost increase is fairly low for most clients (about 5%-10%). If you would like more than 2 million, please contact your broker.

Collision deductible*

Do not want collision coverage
500 (most popular)
1000

Comprehensive (Fire & Theft) deductible*

Do not want comprehensive (fire & theft) coverage
250
500 (most popular)
1000

Would you like to add all perils glass coverage (approx $300/year)?*

Yes
No, do not want glass coverage

Examples of perils that are not covered on a standard auto policy: rock chips to glass, vandalism to the front windshield, shattered glass due to temperature change.

Usage info

Primary operator of this vehicle:*

Occasional operators of this vehicle:

If there are occasional operators that are already listed as primary operators on other vehicles on the policy, you do NOT need to list them here.

Are there any other people in the household with a driver license that are not already listed above or elsewhere on the policy?*

Yes
No

Please note that all drivers living in the household must be disclosed, regardless of whether they have access to your vehicle or not.

Provide details for the other drivers in the household:*

Daily commute (one-way):*

Estimated total annual distance:*

Is this vehicle used for any business or commercial use, such as making deliveries, drive for hire (ex: Uber), or carrying any tools or materials for a trade or work purposes?*

Yes, some business or commercial use
No business or commercial use whatsoever

About how many business kms is this vehicle driven each year?*

Please provide a summary of exactly how the vehicle is being used and/or what is being carried:*

Please note: this form is for streamlining the process of collecting information only. No changes will be made until a broker has reviewed and confirmed the potential changes with you. If you require a time-sensitive change to your insurance policy, please call our office immediately.

By clicking "I agree", I consent and authorize my broker, agent or insurer to collect, use and disclose to appropriate third parties personal information as permitted by law for the purposes necessary to quote risks, investigate and settle claims, and detect and prevent insurance fraud, such as credit information, driving record information, and claims history.

Consent:*

I agree

Broker section

Additional coverages to be added:

Ex: minor conviction rating waiver, disappearing deductible, 13H, etc.

Warning: Client selected "YES" for glass coverage on form. Confirm if client wants AMI coverage:*

Client declined glass coverage coverage
Client accepted AMI coverage (broker must set up new AMI policy)

Broker comments to be uploaded (underwriter approvals, etc)

Special handling instructions for data entry

Broker: have you confirmed effective date is correct? (Liability and confirmation will print with this date)*

Yes
No

Expiry date of liability slip*

PCR-Client: Auto: Add or Sub Vehicle 2.1

Old vehicle info

New vehicle info

Coverage info

Usage info

Broker section

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