Tools & Resources - Leibel MacMillan Insurance

Change Of Address

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 #:

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

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: