Hartland Insurance Brokers - Replace Vehicle

Name(s) of insured(s)
1st insured:
2nd insured:
How can we reach you:
E-mail Address:
Daytime telephone #:
Home telephone #:
Fax #:
Prior Vehicle
Vehicle Make:
Year:
Model:
New Vehicle
Vehicle make:
Year:
Model:
Condition at time of purchase:
Purchase Date:	Date and timeNow
VIN (vehicle ID #):
Any non-factory modifications to the vehicle:	YesNo
Any unrepaired damage:	YesNo
If yes, specify:
Is vehicle leased/financed:	YesNo
If yes, specify:
Name of registrant:
Use of vehicle:
Comments (details if use is other):
Kilometres traveled per year:
How many kilometers one-way for daily commute:
Will replacing this vehicle result in changes in use of other vehicles owned:	YesNo
Diver Information (for all drivers who will be operating this vehicle)
Driver #1
Driver:
Date of Birth:	Date and time
Driver type:
Driver #2
Driver:
Date of Birth:	Date and time
Driver Type:
Driver #3
Driver:
Date of Birth:	Date and time
Driver type:
Effective Date
When will this change be effective:	Date and timeNow
About Your Insurance (Specify the policy to which this change applies)
Company:
Policy #:
Additional Comments:
Name of your broker:

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