Booth-Burnett Insurance
Tools & Resources
Policy Change Forms - Address Change
About You  
Name(s) of insured(s):  
1st insured:
2nd insured:
How can we reach you?
E-mail address:
Daytime telephone #:
Home telephone #:
Fax #:
   
Prior Address  
Number and street:
Apartment#/PO Box:
City:
Province:
Postal Code:
   
New Address  
Number and street:
Apartment#/PO Box:
City:
Province:
Postal Code:
Telephone (home):
Telephone (business):
Ext#:
New Occupation (if applicable):
   
Effective Date  
When will this change be effective?
(dd/mm/yyyy)
Is there any change in use of the vehicle:
Yes     No
How many Kilometers one-way to work from new address:
   
About Your Insurance
Specify the policy to which this change applies:
Policy #1 Policy #2 Policy #3
Type of insurance:
Company:
Policy #:
If the name insured on one of the policies is not yours, please explain:
Additional Comments:
Name of your broker: