Key FOB Declaration Form

                                                                                                                                                       

T// 1.800.613.3705
F// 1.800.613.3708
E// [e-mail]
314-9525 201 St
Langley, BC V1M 4A5

Key FOB Reimbursement Benefit Confirmation
Insured Name(s): ______________________________________________
Policy Number: ______________________________________________
Date of Loss: ________________________________________________
I, _______________________________________ (print name(s)), confirm that I received ____(number) key FOBs when I acquired the vehicle listed on my Optiom policy Declaration page. I confirm that my key FOB was lost or stolen on the date shown above.
I, ________________________________________ (print name(s)), certify that the above information is true and accurate.
_____________________________________________________________
(1st Policy Holder) Print name and Signature
_____________________________________________________________
(2nd Policy Holder) Print name and Signature
_____________________________________________________________
Date Signed