Motor car Proposal Simplified form

PROPOSAL FOR MOTOR CAR INSURANCE

The Company: Reunion Insurance Company Limited

Please give a definite answer to each question

General Information

Email Address

Class of license *

Date driving test passed *

Is Alarm/Immobolizer installed? *

Note: Theft losses are excluded if vehicle is not fitted with an alarm or immobilizer

Do you want passenger liability cover? *

Note: At an additional premium you can have your passengers covered

Do you park in a lockable garage overnight? *

Type of Cover *

Amount Insured *

See Present Value below being 'Proposer's estimate' Including accessories and spare parts

Commencement Date *

Expiry Date *

Vehicle Information

Registration number *

Make and Model *

Local Franchise Holders Dealers

Seating Capacity *

Engine CC *

Year of Make *

Engine Number *

Chassis Number *

Purchase Price *

Make of Value of Radio Cassette Player *

Present Value of Vehicle *

Accident History

Give record of *Accidents and losses during the last three years in connection with every Motor Vehicle and Motor Cycle owned or driven by you and/or by any other person who will regularly drive the car(s) now proposed for Insurance.) *AII Accidents whether resulting in claim or not must be included.

Total Number of Motor Vehicles owned by proposer

Total Number of accidents and losses

Use of car

(a) Solely for Social, Domestic and Pleasure purposes including use by you for driving to or from your permanent place of business? *

(b) For business or Professional purposes by you only? *

(c ) By your Employees or by any other person for Business or Professional purposes? *

(d) In connection with the Motor Trade? *

(e) For the carriage of passengers for hire or reward or will the car be let for hire? *

(f) For Drawing a Trailer? If so, state particulars. *

Driver’s History-'(Please give details for “YES” answers)

Will you allow anyone else to drive? *

Have you or has anyone who to your knowledge may drive:

(a) been convicted of a motoring offence within the last 5 years or received notice of intended prosecution? *

If yes give details

(b) Defective vision or hearing or suffered at any time from diabetes, fits or any heart complaint or any other disease or infirmity. *

If yes give details

(c ) Been disqualified from driving. *

If yes give details

(d) Been involved in any motor accident or loss within the last 3 years? *

If yes give details

(e) Been refused motor insurance, renewal or had any special terms or conditions imposed by any insurers? *

If yes give details

(f) Not attained age of 21? *

If yes give details

Have you previously held or do you now hold a Motor Insurance Policy? If yes, State name of Company & expiry date *

Name of Company

Expiry Date

Are you entitled to a No Claim Bonus? *

If you are entitled to a No Claim Bonus please attach relevant proof

Facts about the Vehicle

(a) Has the engine or body been converted or modified in any way from the Maker's specification?

b) Will vehicle be used for competitions, rallies or trials or any purpose not provided for in the standard use clause?

(d) Are you the owner of any other motor vehicle

(e) Is any Finance Company or other person financially interested

I/we desire to affect an insurance against risks as set forth above in terms of the policy used for this class of business and I/we warrant that the above statements and particulars are correct and complete. I/we hereby agree that this proposal and warranty shall be held to be promissory and be the basis of the contract between me/us and the company. I/we undertake that the vehicle or vehicles to be insured shall not be driven by any person who to my/our knowledge has been refused any motor vehicle insurance or continuation thereof.

Dated *

Place *

Proposer's Signature *

Clear Undo

NB. This Insurance will not be in force until the Proposal has been accepted by the Company. The Company reserves the right to decline any Proposal.