Farm Motor Quote Request / Proposal Form

Transcription

1 5 Park Plaza Knights Way Battlefield Shrewsbury SY1 3AF Tel: Farm Motor Quote Request / Proposal Form Please complete this form clearly using BLOCK CAPITALS Broker Details Brokerage Name : Telephone No : Contact Name : Date submitted : Date quote required by : *IMPORTANT* Should our quotation be accepted, the policy will be issued on a Statement of Fact basis. Documents will be issued in accordance with the information provided on this form. Proposer Details Company Name or Trading Name used by Principal or Partnership Full Name of Principal or each Partner or Director Address Post Code Business Activities (e.g. Farming - Arable, Dairy, Beef, Pigs, Poultry etc; Agricultural Contracting ; Forestry) Renewal Date Current Insurer & Policy Number Target Premium incl IPT Page 1 of 7

2 General Questions 1. Are all vehicles to be insured owned by and registered to the Proposer/Policyholder? Yes No 2. Will any vehicle be used for any purpose other than social, domestic, pleasure Yes No or farm/estate use? 3. Will any vehicle be kept at any location away from the Address shown on page 1? Yes No 4. Will any Goods Carrying Vehicle be used for : (a) Journeys in excess of a 100 mile radius of the farm? Yes No (b) Carriage of Goods for Hire and/or Reward? Yes No 5. Will any Agricultural Vehicles be used for: (a) Tree Felling or Haulage? Yes No (b) Agricultural Contracting? Yes No What is the percentage of contracting in relation to the total farm income? If you have answered No to question 1 or Yes to other questions, please give details below: 6. Have you or any person who may drive: (a) Been refused motor insurance or had a motor policy cancelled or had special terms imposed? Yes No (b) Suffered from diabetes, epilepsy, heart conditions, defective vision or hearing, loss of limb or any other physical, mental or substance abuse condition? Yes No If you have answered YES to question 6 (a) or (b) please give details below: Name Details Onset Date DVLA advised? Licence restricted? You are reminded that all drivers are required by law to inform DVLA if they have any disability, or mental or physical condition which is likely to affect their fitness drive (c) Within the last 5 years been convicted of any motoring offence or have any prosecutions pending? Yes No (d) Been disqualified from driving or had a licence suspended or revoked within the last 10 years? Yes No If you have answered YES to question 6 (c) or (d) please give details below: Driver s Full Name Date Details Offence Code Fine/Penalty Points/ Disqualification Period Page 2 of 7

3 Driver Details Drivers (provide details of all regular drivers) Full Name Date of Birth Occupation (inc. Part-time) Type of Licence (Full UK, EC, etc) Year Test Passed Claims Information Claims list all accidents, claims or losses whether insured or not in the last 3 years. If none state NONE Driver s Full Name Date Circumstances including fault or non-fault Vehicle Total Cost Additional Information Page 3 of 7

4 Private Cars (standard excesses 100 ADF&T, 50 glass) Make Full Model Description Engine size cc Petrol or Diesel Security (Tracker, Alarm, Immobilisor) Main Driver Name Drivers Restriction (IOD, I&S, 2 Named, Any Driver 25+) Youngest Driver Name NCD Years (max 5) Protected NCD? Commercial Vehicles (standard excesses 100 ADF&T, 50 glass) Make Full Model Description Engine size / GVW Main Driver Name Drivers Restriction (IOD, 2 Named, Any Driver 25+) Youngest Driver Name Delete standard 100 excess? Horse/Cattle Lorry annual mileage NCD Years (max 5) Protected NCD? Page 4 of 7

5 Agricultural Vehicles (standard excesses 50 ADF&T, 50 glass) If all vehicles are Comprehensive the cover includes trailers up to 25,000 attached and detached. This excludes fuel bowsers, mobile grain dryers, caravans, trailer tents, passenger-carrying trailers and the like. See below for Quad Bikes, ATVs and Harvesters 5 Make & Model Type of vehicle Make & Model Type of vehicle Specified Trailers (over 25,000) Make & Type Value Page 5 of 7

6 Quad Bikes and ATVs (standard excesses 50 AD&F, 250 Theft, subject to security requirements) Make Model Harvesters (standard excesses 50 ADF&T, 50 glass) Make & Model Type of vehicle NB. 1. For Agricultural Vehicles, Quad Bikes, ATVs and Harvesters driving is by any person aged up to 70. Please provide full details of any driver aged over 70 for whom cover is required. 2. The Excesses shown above are the standard policy excesses, which may be amended in any particular case. Our quotation will show the excesses applicable. Page 6 of 7

7 ADDITIONAL INFORMATION please insert any further information which may influence the assessment and acceptance of this insurance IMPORTANT Should you wish to accept the quotation given this form will be considered as the proposal document and the policy will be issued with a Statement of Fact based on the information provided. Therefore please read the following carefully before you sign and date the Declaration. You must make a fair presentation of the risk. A fair presentation of the risk is one in which every material representation as to a matter of fact is substantially correct and every material representation as to a matter of expectation or belief is made in good faith, and are those facts which the underwriter may wish to know in deciding whether to underwrite the risk and/or the terms upon which to underwrite the risk. The requirement to make a fair presentation of the risk exists throughout the life of the policy. This may be relevant to your activities or to your personal or financial background. Failure to make a fair presentation of the risk could result in your policy being invalidated. Should you be in doubt as to whether information is accurate or material, then you must disclose it to us. We recommend that you should keep a record, including copies of letters and this quote request form, of all information supplied to us for the purpose of entering into this insurance. DECLARATION Before signing the Declaration please check your answers carefully particularly if this Form is not completed in your own hand. I/We declare that to the best of my/our knowledge and belief the answers given are true and complete I/We agree that if any answers have been completed by any other person, such person shall for that purpose be regarded as my/our agent and acting on my/our behalf, and not the agent of Farmsure Underwriters Ltd I/We declare that this Quote Request Form is for insurance in the normal terms and conditions of Farmsure Underwriters Ltd s policy I/We agree that the information provided on this Quote Request Form and any information supplied by me/us shall be incorporated in and form part of the insurance contract. I/We understand that no cover shall be in force until the proposal has been accepted by Farmsure Underwriters Ltd or its agents and that Farmsure Underwriters Ltd reserves the right to reject the proposal, to apply special terms and/or investigate claims. Signed Date of signing Signing this Quote Request Form does not bind the Applicant or the Insurer to complete the insurance. The completed form should be returned to your Broker/Intermediary. Company Registered in England No at 5 Park Plaza, Knights Way, Battlefield, Shrewsbury SY1 3AF Authorised and regulated by the Financial Conduct Authority Page 7 of 7