Substitue a car
  1. If you would like to substitute a car, please complete the form below.

  2. First Name
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  3. Last Name
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  4. Address
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  5. City
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  6. Province
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  7. Postal Code
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  8. How would you like us to contact you?
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  9. Daytime Phone
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  10. Night-time Phone
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  11. Best Time To Call
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  12. Email Address
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  13. Number of vehicles you want to substitute
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  14. Date to Remove Vehicle
    / / Invalid Input
  15. Vehicle Year
    Invalid Input
  16. Vehicle Make
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  17. Vehicle Model
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  18. Will The Vehicle Be Used For Business?
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  19. What distance will the vehicle be driven to work or school
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  20. Comp Deductibles
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  21. Collision Deductibles
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  22. Rental Coverage
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  23. Date to Add Vehicle
    / / Invalid Input
  24. Vehicle Year
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  25. Vehicle Year
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  26. Vehicle Make
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  27. Vehicle Model
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  28. Body Type
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  29. Vehicle Identification Number
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  30. Principal Driver/Operator
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  31. Occasional Driver/Operator
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  32. How is Vehicle Registered
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  33. Cost New
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  34. Lien Holder/Lessee Name
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  35. Lien Holder/Lessee Address
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  36. Garage Address
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  37. Please give any additional comments you feel appropriate. If you have additional information
    where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.
  38. Invalid Input
  39. First Name
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  40. Last Name
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  41. Current Email Address
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  42. Submit This Form
      
 

DeHart & Stauffer Insurance Brokers Copyright © 2014. All rights reserved.
843 King Street WestOshawa, Ontario L1J 2L4 (905) 576-2234Fax 1-253-550-4655