Contact Info: |
| Your name: |
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| Your address: |
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| Your E-mail address: |
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An inaccurate e-mail address means that you WILL NOT receive confirmation that we have received your policy change request and may delay or abort your change request completely. |
| Your policy number: |
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| The name of your insurer: |
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Effective date: |
| What date should we use for these changes? |
Today
or ...
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(These changes CANNOT be back dated)
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Description of the Car: |
| Year |
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| Make |
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| Model |
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| What is the serial number (VIN) of the car? |
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Changes being requested: |
| Change liability coverage limit to: |
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Change following optional accident benefits: |
| Change the weekly income replacement benefits: |
Yes
with a new weekly limit of
(note: $400 is the minimum level)
No
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| Indexation of income replacement and non-earner (incl. student) benefits and all benefit limits to the cost of living |
Deleted
Added
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| Additional $1,000,000 limit for medical, rehabilitation, and attendant-care expenses |
Deleted
Added
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| Increased death benefits |
Deleted
Added
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| All perils coverage (includes collision AND comprehensive) should be .... |
Deleted
Added
If this coverage is to be added, what deductible do you want?
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| Collision coverage should be .... |
Deleted
Added
If this coverage is to be added, what deductible do you want?
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| Comprehensive coverage should be .... |
Deleted
Added
If this coverage is to be added, what deductible do you want?
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| Loss of Use should be ... |
Deleted
Added
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| Non-owned automobile/driver other automobile coverage should be .... |
Deleted
Added
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Suspension of Coverage |
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This car is being taken off the road for an extended period of time.
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| Please suspend coverage until further notice. |
Yes
No
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(NOTE: WHEN COVERAGE IS SUSPENDED, THE CAR IS NOT INSURED FOR USE
ON ANY ROAD. DO NOT DRIVE IT. WHEN YOU ARE READY TO USE THE
CAR AGAIN, YOU MUST NOTIFY US BEFORE DRIVING IT.)
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This car is going to be used on the road again.
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| Please reinstate coverage on my car today |
Yes
No
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(NOTE: The reinstatement of coverage CANNOT be back dated. If coverages
should be reinstated in the future, please tell us when in the Additional
Information section.)
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Additional Information |
Please tell us any additional information that you feel is important
or ask us any questions about insurance on this car
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User Validation
Please select the image that contains a tractor?
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