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St. John's, Antigua
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Private Motor Proposal
POLICY NUMBER:
CERTIFICATE NUMBER:
FULL NAME(S) OF PROPOSER(S):
*
Prefix
First Name
Middle Name
Last Name
Date of Birth
State Period of Driving Experience
Full Address:
P.O. Box
Physical Address:
Email Address:
OCCUPATIONAL TRADE, OR BUSINESS:
TELEPHONE NUMBER(S):
HOME:
WORK:
CELL:
Terms of Insurance:
From
To
*
Registered Letters and Numbers
Colour
Make of Vehicle
Type of Body
H.P. or C.C.
Year of Manu facture
Seating Capacity (including driver)
Proposer’s Estimate of Present Value of Vehicle (including Accessories thereon)
*
Chasis No:
Engine No:
1. a) Will Vehicle be used solely for social, domestic and pleasurable purposes?
*
Yes
No
1. b) If not, state for what purpose will it be used.
i) By you for Professional purposes?
ii) By you personally in connection with your own or your employer’s business?
iii) By employees or other parties in connection with your own or your employer’s business
iv) For the carriage of samples or trade goods or farm requisites, produce or live-stock.
1. c) For any other purpose
*
Yes
No
2. a) State address where the Motor Vehicle is usually garaged.
b) Is it garaged in the open?
c) Is the garage locked?
3. a) Date of purchase of Vehicle by you and from whom purchased?
b) Whether new or second hand.
c) Whether the engine or body has been modified from the Manufacturer’s standard specifications?
d) Whether Vehicle has been wrecked or damaged before?
e) Price Paid
State Name and Address of:
4. a) Owner of Vehicle
b) Person in whose name vehicle is registered
c)Any finance company or other person financially interested in the vehicle
5. Please Select Insurance Required:
*
Comprehensive
Third Party
Please Select Extra perils Required:
Select All
Hurricanes and Earthquake
Riot and Strike
Windshield Damage
Passenger Liability
Please Select Third Party Policy
Basic
Super
Super Plus
6. Are any of the following Extra accessories fitted in the vehicle?
Select All
Am/fm radio
Cassette/CD
Power Steering
Power Windows
Power Locks
Power Mirrors
Air Conditioning
Alloy rims
7. Please give the following in respect to the Proposer.
a) How long have you been continuously driving a vehicle with a valid driver’s license?
b) Whether you had any motor vehicle accidents during the past 5 years
c) Whether you had been charged and/or convicted of any offence in connection with the driving of any motor vehicle during the past 5 years.
8. Do you or any person who to your knowledge will drive, suffer from defective vision or hearing or from any physical infirmity?
9. a) Are you now or have you been insured in respect of this Motor Vehicle? Or any other vehicle?
b) If so, please state the name of the Insurance Company?
c) Are you entitled to a No Claim Discount?
d) Indicate the Policy number?
e) What percentage?
10. a) For how many years up to this date have you previously been insured with any Company for any Vehicle?
COMPANY
YEAR
11. Has any Company or Underwriter ever:
i) Declined your proposal?
ii) Required you to bear the first portion of any loss or imposed other special condition?
iii) Required an increased premium?
iv) Refused to renew or cancelled your policy?
12. Is/Are the Vehicle(s), proposed for Insurance fitted with safety belts?
*
Yes
No
13. Give details of Accident and/or Losses during the past 5 years in connection with any Motor Vehicle owned or driven by you, the Insured or uninsured including any claims outstanding:-
Year
Total Number of Motor Vehicles Owned By Proposer
Total Number of Accidents and Losses
Damage to motor Vehicles owned or Driven by Proposer Paid (No./Amount)
Damage to motor Vehicles owned or Driven by Proposer Outstanding (No./Amount)
Third Party Paid (No./Amount)
Third PartyOutstanding (No./Amount)
Others Paid No./Amount)
Others Outstanding (No./Amount)
14. If Vehicle is being used or driven by members of your family or household or Directors or Partners or others including employees, give full details below.
*
Select All
Any licensed driver 25 years or older with 2 years or more driving experience
Name Policy
NAME
AGE
DRIVING EXPERIENCE
RELATION TO PROPOSER
NUMBER OF ACCIDENTS DURING THE PAST 5 YRS
I/We desire to insure with GENERAL INSURANCE COMPANY LIMITED the motor vehicle/vehicles described in the above Proposal and I/We hereby warrant that the above statements and particulars are true and I/We have not suppressed misrepresented or misstated any material fact and I/We agree that the declaration shall be the basis of the contract between me/us and the Company. I/We further agree that if this proposal in any particular is filled in by you or any other person such person shall be deemed my/our agent and not the agent of the Company. I/We further declare that I/We have read and understood all particulars entered herein and I/We have signed this after verifying the same to be true and complete in all respects.
I/We further declare that I/We am/are willing to accept the Company’s policy subject to the following clauses and warranties;
1. Compulsory Excess; Each and every claim arising out of one accident $
2. Excess of $
of at the time of accident: a) The person driving the vehicle is under 25 years; or b) Holds a valid provisional licence or c) Holds a valid licence but has been driving for less than (2) years.
3. Excess of $
in case of drivers specified in the proposal form.
4. Excess of $
in case of Fire or Theft.
Dated This
Day Of
Year
Place
Signature of Proposer:
Max. file size: 512 MB.
Time
:
Hours
Minutes
AM
PM
AM/PM
NO INSURANCE IS IN FORCE UNTIL THE FULL PREMIUM HAS BEEN PAID AND THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY, WHICH RESERVES THE RIGHT TO DECLINE ANY PROPOSAL
Premium
Gross
NCD
Sub Total
Extra Perils
Under-aged/Inexperienced Driver
Premium
Stamp Duty
Total:
The insurance will not be in force until the proposal has been accepted by the company and premium paid.
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