Policy Change Forms - Tools & Resources

- Change Use of a Vehicle

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Tools & Resources

Policy Change Forms – Delete a Vehicle

About You

Name(s) of insured(s):

1^st insured:

2^nd insured:

How can we reach you?

E-mail address:

Daytime telephone #:

Home telephone #:

Fax #:

Vehicle Information

Vehicle make:

Year:

Model:

If you have more than one vehicle, will the deletion of this vehicle result in changes to the way the remaining vehicles are used?

Yes

Effective Date

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

About Your Insurance
(Specify the policy to which this change applies)

Company:

Policy #:

Reason for deletion the vehicle:

Additional Comments:

Name of your broker:

Disclaimer:

I, the policyholder, fully understand that even though I am requesting a change to my policy. NO CHANGES OF ANY KIND can or will take effect under any circumstance until a licensed broker representing COLLEY INSURANCE deems the change to be legal and/or acceptable. Written notice will be sent to me, the insured, accepting or declining my request.

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