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St. John's, Antigua
+1 268 462 2345/6
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Rental Proposal
POLICY NUMBER
CERTIFICATE NUMBER
Name 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:
*
location in relation to landmarks
Email Address:
*
OCCUPATIONAL TRADE, OR BUSINESS:
*
NUMBER OF DRIVERS EMPLOYED:
Telephone Number(s):
*
Home
Work
Cell
*
Registered Letters and Numbers
Vehicle Colour
Make of Vehicle
Type of Body
Horse Power (Makers Rating)
Horse Power (Tonnage)
Year of Manu- facture
Carrying Capacity (Goods)
Carrying Capacity (Persons)
Proposer’s Estimate of Present Value of Vehicle (including accessories)
Chassis No:
Engine No:
1. State fully the purpose for which the vehicle/s will be used
a) Will the vehicle/s be used as an Omnibus?
*
b) Will the vehicle/s be used for Private/Public hire?
*
c) Will the vehicle/s be used in connection with the Motor Trade?
*
2. a) If used for Carriage of Goods, what is their general nature? State specifically, if explosives or petrol carried.
*
b) Do you undertake cartage for other person?
*
c) Has the Vehicle been altered or adapted to carry load heavier than stated in the Maker’s published specifications?
*
3. a) Will a Trailer be attached to the Vehicle/s?
*
b) If so, state type and value of each
*
4. a) Is/are Vehicle/s your sole and absolute property? (If not, state the name and address of Owner)
*
b) Name of Financier, if any, interested in the vehicle.
*
5. Select Required Insurance
*
Comprehensive
Third Party
5. a) Select Extra Perils
Select All
a) Hurricane & Earthquake
b) Riot & Strike
c) Windshield Damage
d) Passenger Liability
6. If Vehicle/s used for carrying Passengers, are the Passengers carried for hire or reward?
*
7. a) Date of purchase of Vehicle/s by you and from whom purchased?
*
*
b) Whether new or second hand
c) Paid Price
8. Do you or any other person who to your knowledge will drive, suffer from defective vision or hearing or from any physical infirmity?
*
9. Have you or has any other person who to your knowledge will drive, been convicted during the last five years of any offence in connection with any Motor Vehicle or is any prosecution pending?
*
10. Are you now or have you been insured in respect of: a) above proposed vehicle or any other Motor vehicle?
*
Yes
No
b) if so, please state the name of Company or Underwriter
*
c) Policy Number:
*
Are you entitled to a "No Claim Bonus"
*
Yes
No
Percentage %
*
Please enter a number from
0
to
100
.
11. Has any company or underwriter either in respect of you or your partner ever?
i) Declined your or their proposal
*
Yes
No
ii) Required you or them to bear the portion of any loss or imposed other special conditions?
*
Yes
No
iii) Refused to renew or cancelled your or their policy?
*
Yes
No
iv) Required an increased premium?
*
Yes
No
12. State number of motor vehicles owned by you during each of the past three years :
*
Year/# of Vehicles
Year/# of Vehicles
Year/# of Vehicles
13. If there have been ‘accidents or losses during the past 5 years in connection with any motor vehicle owned or driven by you or for you, give particulars in the schedule below:
*
Yes
No
*
Year
Total Number of Motor Vehicles Owned By Proposer
Total Number of Accidents And Losses
PAID/ OUTSTANDING
Damage to motor Vehicles owned (No.)
Damage to motor Vehicles owned (Amount)
Third Party (No:)
Third Party (Amount)
Others (No)
Others (Amount)
1) State address where Motor Vehicle is usually garaged?
*
2) Is the vehicle usually parked within your premises overnight?
*
Yes
No
3) Is it garaged in the open?
*
Yes
No
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
*
AS PER HIRER DECLARATION
List the name drivers
NAME OF DRIVER
AGE
DRIVING EXPERIENCE
RELATION TO PROPOSER
NUMBER OF ACCIDENTS DURING THE PAST 5 YEARS
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 $
*
if at the time of the accident the vehicle is being driven by any person under the age of twenty five (25) years or anyone with a Commercial driving license valid for less than five years.
a) The person is driving the vehicle under 25 years or
b) holds a valid provisional license or
c) hold a license but has been driving less than 2 (two) years
3. Excess of $
in case of drivers specified in the proposal form.
4. In addition to 1,2 and 3 above - Excess of $
in case of Fire or after theft.
Signature of Proposer's:
Max. file size: 512 MB.
Signature:
*
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
Gross:
*
NCD:
Sub Total:
Extra Perils
Under-aged/Inexperienced Driver
Premium
Stamp Duty
Total:
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