Address Change – Melvin E. Van Horn Insurance Brokers Ltd.

1st Insured Name *

First

Last

2nd Insured Name

First

Last

How can we reach you? *

Email *

Home Telephone

Cellular Telephone

Fax

Prior Address: Number and Street *

Apartment # or PO Box

City *

Province *

Postal Code *

NEW Address: Number and Street *

Apartment # or PO Box

City *

Province *

Postal Code *

NEW Home Telephone

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? *

Policy #1: Type of Insurance *

Company *

Policy # *

Policy #2: Type of Insurance

Company

Policy # (copy)

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:

Website