Wiesner Insurance - Change Use of Vehicle

Name(s) of insured(s)

1st insured:

2nd insured:

How can we reach you:

E-mail address:

Daytime telephone #:

Home telephone:

Fax #:

Vehicle Information

Vehicle make:

Year:

Model:

Use of vehicle:

Comments (detials if use is other):

Is this vehicle used out of the province more than 30 days/year:

YesNo

Is this vehicle used for commercial or delivery purposes:

YesNo

Kilometers traveled per year:

How many kilometers one-way for daily commute:

If this vehicle is used for work-related travel, how many kilometers/year (not including travel to and from the workplace):

Effective Date

When will this date be effective:

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

Company:

Policy #:

Will this change in use result in changes in use of any other vehicles owned? If so, please indicate what will change:

Name of your broker:

Please enter the security code:

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