MOTOR PROPOSAL FORM

MOTOR PROPOSAL FORM

IND I V I D U A L
A) Details of Applicant
First
Middle
Last
Full Address for Correspondence
PO Box
City
Tel Nos
Fax No
Email
Occupation
Age
Nationality
B) Details of Vehicle
Make Model
Type of Body
Cubic Capacity
Year of Make
Estimated Market Value
(including Accessories)
Currency
Engine No
Chassis No
Seating Capacity
Registration No
Address where Vehicle is normally Kept
C) Ownership of Vehicle
Name of Owner
Has any person or body any interest in the vehicle

YesNo
If Yes please give details of lender
D) Use of Vehicle

PrivateCommercial
If Commercial, is it used for

Cartage of Applicant's Own GoodsGeneral Cartage of Third PartyCartage of Passenger and their LuggageAny Other Purpose, please specify
E) Details of Driver (Driving, Insurance & Claims History)

Note: Commercial Drivers must have at least three years of experience and must be at least twenty five years old.
(1) Are you now or have you been insured un respect of any other Motor Vehicle

YesNo
If Yes please state the name of the insurance company
(2) Has any insurance company or underwriter ever:
(a) Declined your proposal

YesNo
(b) Required an increased premium or imposed special condition

YesNo
(c) Refused to renew your policy

YesNo
(d) Cancelled your policy

YesNo
(3) Have you or any other person, who to your knowledge, will drive the vehicle
(a) any physical defect or infirmity

YesNo
(c) had fit of any kind ever

YesNo
(b) defective vision or hearing

YesNo
(4) Are you entitle to a "No Claim Bonus" from your previous insurers in respect of any the vehicles described in this proposal

YesNo
If Yes, please attach Renewal Notice. ("No Claims Bonus will be allowed only if notice is attached)
(5) Give particulars of accidents or losses for the last three years in connection with this motor vehicle or cycle owned or driven by you
F) Insurance Cover Required
Please indicate the cover required

Third Party OnlyThird Party, Fire and BurglaryComprehensive
Important Note: No Liability is undertaken until the proposal is accepted by the Company and the Premium is Paid
Limit for Third Party property Damage
Insurance to commence on
Date

MonthDayYear
Agents Name
Agents Code
Signature

Clear
Should be Empty:

MOTOR PROPOSAL FORM

A) Details of Applicant

B) Details of Vehicle

C) Ownership of Vehicle