Motor Proposal Form

What is your first Name?

What is your surname?

What is your gender?

What is your date of birth?

What is your address?

What is your id number?

What is your telephone number?

What is your email address?

Are you a homeowner? Yes/No

What is your marital status?

How many children under 16 do you have?

What do you do? Employed / Self-employed / Retired / Student / Not in paid work right now

What job do you do?

What industry do you work in?

How many cars do you own?

What is the driving licence number?

What licence do you have? Full/Provisional

Which cars are you licenced to drive?

Manual and automatic/Automatic only

Do you have any additional driving qualifications? Yes/No

Do you have any medical conditions or disabilities that the VID needs to be notified of? Yes/No

How many years have you held your current licence?

When do you want cover to commence:

Have you got a full or provisional car driving licence

When was your licence issued?

Is your licence for manual vehicles or automatic vehicles?

How long have you held this licence?

Have you passed any additional driving qualification?

Has any insurer declined your proposal or required you to specifically carry a portion of any loss or, required an increased premium or imposed special conditions or, refused to renew your policy or cancelled your policy?

If yes to the above, state the reason

Name of previous insurer

Would you like to add any additional drivers? Yes/No
You can add up to 2 other people on your insurance.
If YES to any of the above, give details below

What is your name?

What is your date of birth?

What is your gender

Is this the main driver of vehicle? YES No

National ID/Passport No:

Licence type (Full, Provisional)

Country of Issue of Licence

Date of issue of driving Licence (dd/mm/yyyy)

Occupation

Nature of Business

If you are over 70 years of age, have you had a recent medical and been passed fit to drive?

Driver Two details

What is your name?

What is your date of birth?

What is your gender

Is this the main driver of vehicle? YES No

National ID/Passport No:

Licence type (Full, Provisional)

Country of Issue of Licence

Date of issue of driving Licence (dd/mm/yyyy)

Occupation

Nature of Business

If you are over 70 years of age, have you had a recent medical and been passed fit to drive?

Have you or any of the mentioned drivers had any motor accidents, claims or losses in the past 5 years, no matter who was at fault or if a claim was made.? Yes/No
If yes, what was the claim amount?

If you don't tell your insurer about previous incidents or claims, your car insurance may not pay out if you make a claim.

Have you had any driving related convictions, endorsements, penalties, disqualifications or bans in the past 5 years, no matter who was at fault or if a claim was made? Yes/No
If yes, please state the conviction

Have you or has any person who will drive this vehicle been subject to a driving disqualification, charged or convicted of any driving offence during the past (5) five years or is any prosecution pending? Yes/No
If yes, please state the conviction

Have you had any legal convictions, the past 10 years? Yes/No

Has any insurance company refused to meet a claim lodged by you or by any person named as the proposer herein, in respect of motor insurance? Yes/No
If 'Yes', please provide details

Has any insurance company succeeded in denying a claim lodged by you or any person named as the proposer herein, on the grounds of non-disclosure, misrepresentation and/or fraud, in respect of motor insurance? Yes/No
If 'Yes', please provide details

Is there any additional information or detail of which you are aware, and which may assist the ECGC to better assess the nature of the risk? Yes/No
If 'Yes', please provide details

Has any insurance company in connection with this class of insurance

declined to accept a proposal from you?

cancelled a policy, contrary to your wishes?

declined to renew a policy, contrary to your wishes?

If 'Yes', please provide details

VEHICLE DETAILS

What is the registration?

What make is the car?

What is the model?

What fuel does it run on?

What is the transmission? a) b)

What is the engine size?

What is the Chassis Number?

What is the Engine capacity?

What is the year of manufacture/registration?

What is the trim?

What type of alarm does the car have?

Is the car fitted with a tracking device? Yes/No

Is the car an import? Yes/No

Has the vehicle been modiﬁed or converted in anyway? Yes/No

What is the Value of the car?

VEHICLE USAGE

How do you use the car?

How many kilometres does the car do a year?

Where is the car kept during the day?

Where is the car kept at night?

Do you drive any other cars? e.g. company vehicles, partner’s car etc Yes/No

COVER POLICY DETAILS

What type of cover are you looking for?

Who is the main driver of the vehicle?

How much voluntary excess are you prepared to pay in case of a claim?

Are you or will you be the registered keeper and legal owner? Yes/No

How would you normally pay your cover for your insurance?

On which days within the next 30 days would you like your cover to start?

How many years of claims discount do you have? This will be detailed in your latest policy details

Optional extras

Would you like your policy to include legal cover?

Would like your policy to include personal injury cover?

Would like your policy to include breakdown cover?

Would you like your policy to include courtesy car cover?

GENERAL HEALTH QUESTIONS

Do you suffer from diabetes, epilepsy, heart condition, hearing impairment, defective vision or physical disability, mental disability or disease, which could affect your/their ability to drive?

REASONABLE PRECAUTIONS AND FRAUDULENT ACTS

You must take all reasonable precautions for the maintenance and safety of the Insured Property and prevention of loss. We will not be liable for any loss, damage, injury or liability arising from a deliberate or fraudulent act committed by you or on your behalf

DECLARATION.

I warrant

that to the best of my knowledge and belief that all statements and particulars given in this proposal whether in my own hand or not are true and complete in every respect and I have not withheld any material facts.
that I agree to give immediate written notice to the Company of any alteration of the risk herein submitted and subject to such notice the payment of each renewal premium shall be considered to have reaffirmed the answers to the questions on the proposal
that this Proposal form shall be the basis of the contract between the Company and myself.
that my insurance shall not be effective until I have paid the premium.
that I understand that non-disclosure or misrepresentation of a material fact may entitle the Company to void the Insurance

Signature of Proposer

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Motor Proposal Form

Driver Two details

VEHICLE DETAILS

VEHICLE USAGE

COVER POLICY DETAILS

GENERAL HEALTH QUESTIONS

REASONABLE PRECAUTIONS AND FRAUDULENT ACTS

DECLARATION.