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Policy Change Request: Auto: Add Driver
This form collects the key information required to add a new driver to an existing policy.
Important:
Please note that submitting this policy change request form does not imply that coverage has been added. A licensed broker must follow up and confirm that the change has been accepted before coverage begins, and additional information may be required. Please contact our office with any questions or concerns.
At any time, you can save your work in progress and come back by clicking the "Save and Continue Later" button near the bottom of the page. Once the form is complete, please make sure to click the "Submit" button to finalize the form for our brokers to review.
Assigned Broker
Any Available Broker
Ashley Carducci
Jacqueline Orthner
John Yu
Karen Cloney
Mackenzie Bell
Nik Bolianatz
Rick Cloney
Scott Marit
Policy number
*
Policyholder(s)
*
Full name of driver to be added:
*
Will this driver also to be added as a joint policy holder (signature required)?
Yes
No
If the driver is also a registered owner of the vehicle on the policy, then they must be added as joint policy holder.
Email
Best primary contact number
Please verify current address
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
New Driver Info
Effective date to add new driver
Effective Time
:
HH
MM
AM
PM
Which vehicle will this driver be driving?
Will this new driver be the primary operator or occasional operator of the vehicle?
Primary operator
Occasional operator
Does this driver have their own vehicle and insurance policy elsewhere?
Yes
No
Confirm total daily commute for this vehicle (one-way):
Please choose
0 km; recreational use only
3 km or less
4-5 km
6-7 km
8-10 km
11-12 km
13-15 km
16-20 km
21-25 km
26-30 km
31-35 km
Over 35 km
Estimated total annual distance for this vehicle:
Please choose
Please choose
5,000 KM or less
8,000 KM
10,000 KM
12,000 KM
15,000 KM
20,000 KM
25,000 KM
30,000 KM or more
Is this vehicle used for any business or commercial use, such as making deliveries, drive for hire (ex: Uber), or to carry 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 choose
5,000 KM or less
8,000 KM
10,000 KM
12,000 KM
15,000 KM
20,000 KM
25,000 KM
30,000 KM or more
Please provide a summary of exactly how the vehicle is being used and/or what is being carried:
*
Relationship to current policyholder
Please choose
Child
Cohabitant
Common-law
Parent
Spouse
Other
Please specify relationship to policyholder:
*
Driver license number
*
Date of Birth
Gender
Female
Male
Marital Status
Please choose
Common-law
Married
Single
What is this driver's occupation? Please type in box.
Note: some occupations may be eligible for additional discounts.
How many years has this driver held a valid class 5 driver license?
Please choose
Less than 1 year
More than 1 and less than 2 years
More than 2 and less than 3 years
More than 3 and less than 4 years
More than 4 and less than 5 years
More than 5 and less than 6 years
More than 6 and less than 7 years
More than 7 and less than 8 years
More than 8 and less than 9 years
More than 9 and less than 10 years
More than 10 and less than 11 years
More than 11 and less than 12 years
More than 12 and less than 13 years
More than 13 and less than 14 years
More than 14 and less than 15 years
Over 15 years
Does this driver have a Driver Training Certificate?
Yes
No
How many years has this driver been insured as a driver on any insurance policy?
Please choose
Less than 1 year
More than 1 and less than 2 years
More than 2 and less than 3 years
More than 3 and less than 4 years
More than 4 and less than 5 years
More than 5 and less than 6 years
More than 6 and less than 7 years
More than 7 and less than 8 years
More than 8 and less than 9 years
More than 9 and less than 10 years
More than 10 and less than 11 years
More than 11 and less than 12 years
More than 12 and less than 13 years
More than 13 and less than 14 years
More than 14 and less than 15 years
Over 15 years
In the past 9 years, was this driver considered at-fault for any automobile accidents? If so, how many total?
Please choose
None
1
2
3 or more
Accident #1: Date
Accident #2: Date
Accident #3: Date
In the past 3 years, how many tickets has this driver received in total? (Speeding, stop sign, careless driving, etc.)
Please choose
None
1
2
3
4
5 or more
Ticket #1: Conviction Date
Ticket #1: Type
Please choose
Minor: Speeding, stop sign, etc.
Major: Careless Driving, stunting, etc.
Criminal: DUI, Fail to remain, etc.
Ticket #2: Conviction Date
Ticket #2: Type
Please choose
Minor: Speeding, stop sign, etc.
Major: Careless Driving, stunting, etc.
Criminal: DUI, Fail to remain, etc.
Ticket #3: Conviction Date
Ticket #3: Type
Please choose
Minor: Speeding, stop sign, etc.
Major: Careless Driving, stunting, etc.
Criminal: DUI, Fail to remain, etc.
Ticket #4: Conviction Date
Ticket #4: Type
Please choose
Minor: Speeding, stop sign, etc.
Major: Careless Driving, stunting, etc.
Criminal: DUI, Fail to remain, etc.
Ticket #5: Conviction Date
Ticket #5: Type
Please choose
Minor: Speeding, stop sign, etc.
Major: Careless Driving, stunting, etc.
Criminal: DUI, Fail to remain, etc.
In the past 3 years, has this driver's insurance policy been suspended or lapsed?
*
Please choose
No
Yes, due to NSF/non-payment of premiums
Yes, due to convictions
Yes, due to other reasons
By clicking "I agree", I understand and agree to the following:
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.
I understand that 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 after submitting this form.
Consent:
*
I agree
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