Policy Information Policyholder Name*
Email Address*
Primary Phone Number*
Province* Please Select Province Nova Scotia New Brunswick PEI Newfoundland & Labrador Ontario Alberta Yukon Nunavut Northwest Territories
Personal Information Consent* For the purposes of providing insurance quotations, completing applications, issuing new policies or subsequent renewals or change in coverage and payment thereof, I authorize Cheep Insurance and/or its insurance suppliers, on behalf of myself and other applicants/policyholders listed to collect, use and disclose personal information, including relevant reports containing policy and claim history up to 25 years, for the purposes of assessing, managing and underwriting risk, determining a premium, establishing eligibility for a premium payment plan (as applicable), investigating and settling claims, analyzing business results, detecting and preventing fraud as permitted by law and in accordance with its privacy policies.
I understand that Cheep Insurance is gathering this consent on behalf of multiple insurance companies and that I can withdraw my consent at any time.
Change Request Information What date would you like the change to take place?* MM slash DD slash YYYY
Will you be the registered owner of the vehicle you'd like to add to the policy?* Note: you have 30 days to register the vehicle in your name after adding it to your policy. If the vehicle will be registered to you within 30 days, please answer "Yes" to this question.
UNABLE TO ADD VEHICLE TO POLICY Please note that you cannot add this vehicle to your policy because you are not the registered owner. You cannot insure something you don't own. The owner of the vehicle will need to set up their own insurance policy in their name and insure the vehicle that way. If the vehicle is (or will be) registered to your spouse or commonlaw partner, we can add them as a policyholder on your policy and add the vehicle to the policy. If this is the case, please give us a call at 1.866.922.4337 and explain the situation and our team will walk you through next steps. Vehicle Information Vehicle Year*
Vehicle Make*
Vehicle Model*
VIN#*
Vehicle Use Do you use your vehicle to drive to work or school?* Use of Vehicle How do you travel to work or school?*
Commute How many km do you drive one way to work or school?*
How many km do you drive your vehicle in a year? (Approx.)*
Is there any business, commercial, delivery, ride-sharing or rental use of this vehicle?* Business Use Please describe the business use*
What percentage of the vehicle use is for business purposes?
Is the vehicle used to carry any tools, products, or equipment for business or commercial purposes? Please provide a description of the tools, products or equipment being carried for business or commercial purposes
Is there any business-related signage on your vehicle? Please provide a description of any business related signage on the vehicle
Vehicle Coverage What liability limit (PL&PD limit) would you like for this vehicle?* Third Party Liability protects the insured Nova Scotia driver and/or the registered vehicle owner in the event they cause injury, death or property damage to a third-party resulting from the driver's negligence in operating the motor vehicle
Direct Compensation Property Damage (DCPD)* Coverage for damage to your vehicle, its contents, and the loss of use due to an accident, if you are not at fault in an accident.
Accident Benefits* Accident Benefits provides benefits if you are injured in an automobile accident, regardless of who caused the accident.
Important: Under Ontario's July 1, 2026 auto insurance reforms, the option to opt out of certain Accident Benefits is not available until your first policy renewal occurring after July 1, 2026. Your current Accident Benefits coverage will remain in effect until that renewal. If you would like to review or make changes to your Accident Benefits coverage at the time of your renewal, please contact our team and we will be happy to discuss the available options with you. Medical, Rehabilitation & Attendant Care Benefits* Mandatory Limit $130,000 (Non-Catastrophic Buy-Up) $1 Million (All Injuries Buy-Up)
Helps pay for medical treatment, rehabilitation, and attendant care if you're injured in an automobile accident. This coverage is mandatory and cannot be removed, although you may choose to purchase higher limits.
Income Replacement Benefit* $400 (Standard limit) $600 limit $800 limit $1,000 limit Opt-Out (not recommended)
Helps replace part of your income if you or another covered person can't work because of injuries from an automobile accident. If you opt out of this important coverage, people covered under your policy won't receive compensation for lost income if they suffer an injury in an automobile accident.
Non-Earner Benefit* $185 (Standard limit) Opt-Out (not recommended)
Provides financial support of up to $185 per week during recovery if an auto accident keeps you or another covered person from leading a normal life and you are not eligible for Income Replacement. Note: must be considered an eligible student or unemployed individual for this benefit to be payable.
Caregiver Benefit* $250/$50/Week Limit (Standard limit) Enhanced Coverage - Includes Eligible Non-Catastrophic Impairments Opt-Out (not recommended)
Provides a weekly benefit if you were the primary caregiver for dependant(s) (such as children or aging parents) before an auto accident and are unable to continue providing that care due to injuries cause by the accident. The benefit pays $250 per week for the first dependant requiring care and $50 per week for each additional dependant requiring care while your recover. Under a standard policy, this benefit is available only if you sustain a catastrophic impairment (a severe injury that meets the definition set out in Ontario's Statutory Accident Benefits Schedule (SABS)). Selecting the enhanced coverage extends eligibility to certain non-catastrophic impairments.
Lost Education Expenses* $15,000 (Standard limit) Opt-Out (not recommended)
Helps cover prepaid or lost tuition, room and board, and books up to $15,000 per claim If an auto accident prevents you or another covered person from attending an eligible educational program.
Expenses of Visitors Benefit* Standard limit Opt-Out (not recommended)
Helps cover reasonable and necessary travel and accommodation expenses for eligible visitors, such as parents or siblings, if you or another covered person is injured in an auto accident.
Housekeeping & Home Maintenance Expenses* Catastrophic Impairment Only - $100/Week Limit (Standard limit) Enhanced Coverage - Includes Eligible Non-Catastrophic Impairments Opt-Out (not recommended)
Helps cover reasonable housekeeping and home maintenance expenses such as cleaning and snow removal if you're unable to perform these tasks because of injuries from an auto accident. Under a standard policy, this benefit is available only if you sustain a catastrophic impairment (a severe injury that meets the definition set out in Ontario's Statutory Accident Benefits Schedule (SABS)). Selecting the enhanced coverage extends eligibility to certain non-catastrophic impairments.
Damage to Personal Items* Included (Standard) Opt-Out (not recommended)
Helps pay to repair or replace certain personal items, such as clothing, glasses, hearing aids, or mobility devices, that are damaged in an automobile accident. If you decline this coverage, these items would not be covered
Death Benefit* $25,000/$10,000 (Standard limit) $50,000/$20,000 Opt-Out (not recommended)
Provides compensation to eligible family members if you or another covered person dies due to an auto accident. Option 1 provides $25,000 for a spouse and $10,000 for dependants. Option 2 provides $50,000 for a spouse and $20,000 for dependants.
Funeral Benefit* $6,000 limit (Standard limit) $8,000 limit Opt-Out (not recommended)
Helps cover funeral expenses if an insured person dies as a result of an automobile accident. If you decline this coverage, no Funeral Benefit would be payable.
Dependant Care* Opt-Out (Standard) $150 limit ("Buy-Up")
Helps cover reasonable and necessary additional costs to care for dependant(s) (such as children or aging parents) if injuries sustained in an auto accident result in you needing to pay someone else to provide that care. This benefit reimburses eligible replacement care expenses incurred because of your injuries.
Indexation Benefits* Opt-Out (Standard) Opt-In
Helps protect the value of certain eligible benefit payments and monetary limits by adjusting them annually to reflect changes in the cost of living. Without this coverage, eligible benefit amounts and limits remain at the amounts shown in your policy and are not adjusted for inflation.
Would you like collision coverage for this vehicle?* Collision coverage pays for the cost of repairing or replacing your vehicle up to the actual cash value if it collides with another vehicle, the ground, or an object on the ground such as a guard rail less the deductible you choose.
Collision Coverage Which deductible would you like to go with for your collision coverage?* Please choose the deductible you would like for Collision coverage. The deductible is the amount you are responsible to pay in the event of a collision claim.
Would you like comprehensive coverage for this vehicle?* Comprehensive coverage for the cost of repairing or replacing your vehicle up to the actual cash value if it's damaged by other unexpected situations such as falling or flying objects, vandalism, fire, theft or attempted theft, glass repair, a natural disaster, or a riot or civil disobedience less the deductible you choose
Comprehensive Coverage Which deductible would you like to go with for your comprehensive coverage?* Please choose the deductible you would like for Comprehensive coverage. The deductible is the amount you are responsible to pay in the event of a comprehensive claim.
Would you like Accident Protection Coverage* With this coverage, your first at-fault accident will be “forgiven”. This means your premium won't increase as a result of the accident, for as long as Accident Protection remains on your car insurance policy and you remain with the same insurance carrier.
Replacement Rental Car (Sef 20 - $1200 Limit)* Provides coverage for reasonable expenses incurred for a rental vehicle or other transportation, if the insured vehicle is not able to be driven due to an insured loss or insured damage. Coverage limits apply (limits vary by carrier).
Extending your coverage to a Rental Car (Sef 27 - $40K Limit)* Covers you for damage to a rented private passenger vehicle should you have an at-fault accident – coverage is based on your policy limits and for a specified vehicle value limit.
Emergency Roadside Service Coverage - (Sef 35)* Provides reimbursement for towing and emergency service expenses if the vehicle is disabled (e.g. flat tire, breakdown). Does not cover the cost of parts, supplies, etc. Damage does not have to be from an insured peril for this coverage.
Waiver of Depreciation Coverage (Brand New Vehicle Only) - (Sef 43R)* A depreciation waiver means your car insurance policy will pay out the full purchase price for your vehicle if it is stolen or damaged beyond repair in an accident (no depreciation will be applied). This coverage will apply for a set period of time after the new vehicle is purchased.
Please Upload Bill of Sale Ontario Only - OPCF 48* If you are injured in a car accident and pursue a lawsuit, the defendant usually gets a deduction for your pain and suffering damages. OPCF 48 reduces this deduction.
Family Protection (SEF 44)* Provides limited protection to the insured in the event of bodily injuries caused by another motorist who carries less Third-Party Liability than the insured.
Is there a lease or financing on the vehicle?* Full name & address of the lessor (company you're leasing from)
Full name & address of the lienholder (lender)
Is the vehicle modified in any way?* Modifications Please describe the modifications.*
Condition of the Vehicle* How Many KM were on the vehicle when purchased*
Date of Purchase* MM slash DD slash YYYY
Is there any existing damage to the vehicle?* Existing Damage Please describe any existing damage to the vehicle?*
Driver Information Who drives this vehicle primarily? First Last
Is there anyone living with you that has a drivers license and does not have their own insurance policy?* Additional Driver 1 Name* First Name Last Name
Driver’s License Number*
Relationship to You*
Which vehicle do they drive and how often?*
Additional Driver 2 Name First Last
Driver's License Number
Relationship to you
Which vehicle do they drive and how often?
Discount Information Does your vehicle have snow tires?* Does your residence have private parking?* A discount could be available for all private passenger vehicles with a private space for parking, such as a private garage, driveway, or carport.
Do you consent to a soft credit check to determine if you’re eligible for a credit-based discount (up to 30% savings)?* Some of the insurance companies we work with are now offering discounts based on soft credit check results. This does not impact your credit score, and we don't see your credit information, the system just determines the discounts available.
Credit Consent Statement* For the purposes of providing insurance quotations, completing applications, issuing new policies or subsequent renewals or change in coverage and payment thereof, I authorize Cheep Insurance and/or its insurance suppliers, on behalf of myself and other applicants/policyholders listed to collect, use and disclose personal information, including relevant reports containing policy and claim history up to 25 years and credit information, such as my credit score, as applicable to the insurance company supplier, for the purposes of assessing, managing and underwriting risk, determining a premium, establishing eligibility for a premium payment plan (as applicable), investigating and settling claims, analyzing business results, detecting and preventing fraud as permitted by law and in accordance with its privacy policies.
I understand that Cheep Insurance is gathering this consent on behalf of multiple insurance companies and that I can withdraw my consent at any time.
Comments Do you have any other comments to make for this change?
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Most policies insured with Cheep Insurance are Agency Bill/IFS financed policies. You can determine who manages your payments by following the directions below. If you are still not sure who manages your payments, call our team as funds paid directly to the insurance company when they should go to IFS will cause large delays.