All-Risks Insurance Brokers Limited 2020/12/31 Page 1

Policy Change Request

AUTOMOBILE Policy # WFA06503947

Company Broker/Agent
Name Nordic Insurance Company - Fa... Name All-Risks Insurance Brokers
Limited, Willowdale
Address 6925 Century Ave Address 344 Sheppard Avenue East, Unit
3
City Mississauga, Ontario City North York, Ontario
Postal Code L5N 7K2 Postal Code M2N 3B4
Telephone: (800)668-1000 Telephone: (647) 847-9066
Contract#: 3400

Applicant Description of change

Customer # 160752 Bill Method DIRECT BILL
Name Maicon Dos Santos Change Type ENDORSEMENT
Name2
Address 38 Kingsdale Ave.
City, Prov. North York, Ontario
Postal Code M2N 3W4

Effective Date of Change

From: Year Month Day Time To: Year Month Day Time
2020 12 31 04:04 p.m. 2021 07 30 12:00 a.m.

Summary of Changes (A)dd / (C)hange / (D)elete

Vehicle # 0001 Changed
Coverage(s) Deleted

APPLICANT DATA

(C) APPLICANT INFORMATION CHANGED

VEHICLE(S)

Veh # Year Make Model

0001 2013 DODGE/RAM GRAND CARAVAN SXT

Body Code Total Premium

Mini Van 370.00

VIN 2C4RDGBG3DR622490 Veh. Code No. of Cyls.

Purchase Date Purchase Price List Price
Condition Usage Damage
Is Leased
Is Mod/Custom
Annual Distance
Commute (km)
Bus. Use (Km)
% Bus Use
Inspection Details
Ride Sharing
Autonomous Braking

COVERAGE(S)
Type of Coverages Limit 1 Ded. Full Term Premium Net Change Premium
(D) Third Party Liability - Direct ... 0 639.00 0
(D) Third Party Liability Limit - B... 1000000 2003.00 0
(D) Accident Benefits 4321.00 0
(D) Third Party Liability Limit - PD 1000000 17.00 0

To verify hardcopy, click on SignatureMaster™ website "Verify Document" link, enter Document Key: 570266FD-0D532B57-B5EB97C4-6A0AF20B-C43B4AE7
JANEZHA 12/31/2020 4:04:53 PM
 All-Risks Insurance Brokers Limited 2020/12/31 Page 2
Policy Change Request
AUTOMOBILE Policy # WFA06503947
(D) Uninsured Automobile Cove... 62.00 0
(A) Comprehensive
(D) 44 Family Protection or Terri... 1000000 16.00 0

REMARKS

(A) Policy change

Signed electronically by

Maicon Dos Santos

on 2020-12-31 21:38:43 GMT Xinpei (Jane) Zhao
__________________________________________ Dec 31, 2020
_____________________ ____________________________
Insured Signature Date Authorized representative

JANEZHA 12/31/2020 4:04:53 PM