MOTOR VEHICLE PROPOSAL FORM (PRIVATE & COMMERCIAL)

MOTOR VEHICLE PROPOSAL FORM (PRIVATE & COMMERCIAL)
Adj. Assoc. Int. School, 65 Patrice Lumumba Road. Airport Residential Area. P. O. Box CT 6342 Cantonments, Accra Tel: +233-302-778106, Fax+233-302-782871
Please Provide Definite Answers to Each Question
FULL NAME OF PROPOSER:
_ AGE:
TEL. NO.:
TEL. NO.:
E-MAIL ADDRESS:
example@example.com
FAX:
OCCUPATION OR BUSINESS:
VEHICLE REGISTRATION NUMBER

a. Private and Business (as individual use) e. Use for carriage of own goods Please indicate accessories fitted (e.g.: radio cassettes / CD/ DVD player, etc.) and their values b. Private and Business (corporate use) f. Use for general cartage of others goods Engine No.: с. Тахі g. Motor cycle 1. INDICATE USE OF VEHICLE: PRIVATE / COMMERCIAL VEHICLE: (Tick where applicable) 2. a. Are you the owner of the vehicle(s)? YES NO Is it registered in your name? YES NO Chassis No.: ESTIMATED VALUE OF VEHICLE YEAR OF MAKE

TYPE OF BODY

	VEHICLE REGISTRATION NUMBER	MAKE & MODEL OF VEHICLE	(e.g. Saloon, Van, Pick up, etc.)	CUBIC CAPACITY	SEATING CAPACITY	-	-

If NO, state in whose name it is registered and the address
If NO, state in whose name it is registered and the address
If so give particulars of credit

4. a. Has the vehicle proposed for insurance ever been insured? YES NO b. Is the vehicle subject to a loan or hire purchase agreement?
If so give particulars of credit
If so give particulars of credit

YES NO IF YES, state the nature of defect of infirmity 3. Have you or has any person who to your knowledge will drive the vehicle any physical defect or infirmity?
YES NO IF YES, state the nature of defect of infirmity
b. If yes, please state name of insurance company
b. If yes, please state name of insurance company

c. How many years has the vehicle been insured?
b. If yes, please state name of insurance company
c. How many years has the vehicle been insured?

5. a. Are you entitled to a No Claim Discount in respect of this vehicle from your previous insurers? YES NO
COMPREHENSIVE

7. a. Would you like to increase the Third Party Property Damage (TPPD) Limit under your policy? YES NO b. If yes, indicate the percentage, and attach a renewal notice from your previous insurer.
COMPREHENSIVE

6. Indicate the type of cover preferred: (please tick where applicable)
COMPREHENSIVE

THIRD PARTY, FIRE & THEFT THIRD PARTY, ONLY
Note: The standard TPPD limit is GH₵ 1,000.00
b. if yes, please indicate the TPPD limit you wish to have for your policy. GH
_ To expire on
_ To expire on
_ To expire on
Agent / Broker
I/We hereby declare that above statement is true and correct, and also agree that this proposal and Declaration shall form the basis of this contract.
Should be Empty:

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MOTOR VEHICLE PROPOSAL FORM (PRIVATE & COMMERCIAL)

Please Provide Definite Answers to Each Question