Goods CarryinG VehiCle insurance. Proposal Form November 2006 Edition
|
|
- Edmund Parks
- 5 years ago
- Views:
Transcription
1 Goods CarryinG VehiCle insurance Proposal Form vember 2006 Edition
2 Important tice To apply for the Goods Carrying Vehicle Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue or black ink). Insurance begins when AXA Insurance has accepted your application. You must give full and true answers to all questions. If you do not do so, your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied to AXA Insurance (including copies of correspondence). You should disclose all material facts as failure to do so could invalidate the policy. A material fact is information which is likely to influence an insurer in the assessment and acceptance of a risk. You must disclose all material facts about yourself, any other drivers, the vehicle and its use that is known to you at the time of applying for this insurance. If you have any doubt as to whether a fact is material or not then please disclose it now to avoid any chance to invalidating the policy. A copy of this Proposal can be supplied on request, within a period of 3 months after its completion. A copy of the Policy is available on request. Law Applicable to Contract You and We are free to choose the laws applicable to the policy. As we are based in England we propose to apply the laws of England and Wales and by purchasing this policy you have agreed to this. PArt A - Proposer and Cover Details 1 title Mr/Mrs/Ms/Firm 2 3 Forenames if individual 4 Address Postcode* *A postcode must be supplied and can be obtained most easily from your driving licence. 5 Daytime telephone number Evening telephone number 6 E mail address 7 Date of birth if individual 8 If you are an individual, are you full time employed? 9 Please state your type of business 10 Number of years in business 11 If more than one business, give full details 12 Other business insurance held? 13 Budget Plan Do you wish to pay by instalments? If, please complete a Budget Plan application 2
3 SECtION 1 - Cover requirements 1 Effective start date of cover? 2 Expiry Date (if less than 12 months)? 3 type of Cover required? Comprehensive Third Party, Fire and Theft Third Party only SECtION 2 Your Vehicles and Attached trailers This is not an agreed value contract but the current value You declare below must be an accurate assessment of the the total value of the vehicle including the most expensive trailer it may tow otherwise this may prejudice you in the event of a claim. 1 Make 2 type of body (State if van, lorry, pick-up, tipper, articulated lorry etc.) 3 Carrying capacity tonnes 4 Gross plated weight tonnes 5 Year manufactured 6 Date purchased 7 Current value 8 Seating capacity 9 Is your vehicle signwritten (State ne, Magnetic/Removable signs, Vinyl text or graphics, Full wrap or Signwritten) 10 Is your vehicle internally fitted out? (Please state value if fitted out) 11 Annual Mileage 12 registration number 13 Please state Use of the vehicle Carriage of Own Goods Use for Hire and reward Social Domestic and Pleasure Use only SECtION 3 Your Drivers Yourself Date of birth Full Provisional International ne Give the date you passed your UK test
4 Additional Driver Date of birth Full/EU Provisional n EU ne Give the date you passed your UK test Additional Driver Date of birth Give the date you passed your UK test Full/EU Provisional n EU ne Additional Driver Date of birth Give the date you passed your UK test Full/EU Provisional n EU ne
5 Additional Driver Date of birth Give the date you passed your UK test Full/EU Provisional n EU ne Additional Driver Date of birth Give the date you passed your UK test Full/EU Provisional n EU ne Additional Driver Date of birth Give the date you passed your UK test Full/EU Provisional n EU ne
6 SECtION 4 Optional rebates 1 Permitted Drivers Policyholder only Drivers under 2 excluded Named drivers only Proposer and Spouse Drivers under 0 excluded 2 Voluntary Excess (only available if Comprehensive cover selected) Nil (none required) Voluntary contribution towards each claim for own loss or damage (in addition to any other amount you must pay in the policy). te: the reduction in the gross premium will not exceed the amount of the voluntary excess SECtION 5 Your Previous Insurance Details 1 Have you or any driver named in Section 3 had any motor vehicle insurance declined, withdrawn, cancelled or subjected to an increased rate or special conditions? 2 If you have ticked the YES box, please give full details here: 10 3 Are you at present or have you ever been insured in respect of any motor vehicle? 4 If YES, give Insurers Name 5 Date cover finished* 6 *If more than 3 months before our cover starts, please give reason: If you claim a no claims discount you must provide evidence in the form of your previous insurer s last renewal notice. (Photocopies not acceptable) 7 Please state the number of years entitlement Years 8 If available do you wish to protect your Claims Discount 6
7 SECtION 6 Additional Information About the Vehicle in Section 2 1 Do you own any goods-carrying or private type vehicle other than that described in Section 2 of this form? 2 If YES, please give details of vehicles here along with details of any claims discounts currently earned on those vehicles 3 Will any vehicle or trailer carry goods of an explosive, inflammable, corrosive, toxic or otherwise dangerous nature and or display Hazchem plates? 4 Is the vehicle modified or altered from manufacturer s original specification? (including bodywork, wheels or engine, e.g. body kit, engine or carburettor change, wide wheels) 5 Who owns the vehicle in Section 2? Yourself Other than Yourself* 6 *If you have ticked this box, please give details here: 7 Is the vehicle registered in your name? 8 If, please give details here: 9 Is the vehicle in Section 2 left in the open overnight? 10 If, please give details here: 11 Will the vehicle be used within any secure areas where access is controlled by an airport or aerodrome authority which are areas that are considered to be airside. If yes provide full information in the box below.
8 SECtION 7 Drivers History 1 Have you or any person named in this proposal (a) in the last three years, had any accidents, claims or losses, regardless of blame, in connection with any vehicle owned or driven by you or them? (b) in the last five years i) been convicted of any motoring offence? ii) had a fixed penalty fine imposed resulting in endorsement of a driving licence? iii) received a notice of intended prosecution for any motoring offence other than in connection with i) and ii) above? (c) at any time been disqualified from driving for any motoring offence? (d) suffered from any physical or mental disability or infirmity, psychiatric illness or mental disorder, heart condition, epilepsy, diabetes, multiple sclerosis, Parkinson s disease, a stroke, brain surgery or tumour or a severe head injury, eye disorder or disease, continued misuse or dependency on alcohol, illicit drugs or chemical substances, or any other condition requiring current treatment involving the habitual use of drugs? te: All these conditions are DVLA notifiable. If you have ticked a box, please give full details in the corresponding sections (a), (b), (c), and (d) below: (A) Accidents, Claims and Losses Mr, Mrs, Ms Name Date of accident/ claim/loss Own Costs third Party Costs Did You Lose your N.C.D.? / Was your Driver convicted? / Was your Driver at fault? / Was there any third party injury? / What happened?
9 (B) And (C) Convictions, Impending Prosecutions & Disqualifications Mr, Mrs, Ms Forename Date of conviction/ fixed penalty/ impending prosecution Amount of fine Endorsement offence code Licence Endorsed? / Penalty points Length of ban? (Yrs/Mnths) Did accident occur? / (D) Disabilities & Other Conditions (te: A Medical Report May Be Required) Mr, Mrs, Ms Name Date diagnosed Is he/she being treated now? / Is he/she taking drugs? / Name of drug(s) Description of disability/condition
10 SECtION 8 Detached trailers 1 Is any cover required for trailers when detached from the vehicle? If you have ticked the box, complete the details required in the section below: Identification or chassis no. of trailer Value of trailer Cover required Gross Plated Weight Carrying Capacity Make and type Identification or chassis no. of trailer Value of trailer Cover required Gross Plated Weight Carrying Capacity Make and type Proposers tes Use a separate form for each vehicle to be insured. Answer all questions, use ticks where indicated, initial any alterations. A specimen of the policy document, giving full details of the standard cover can be made available for inspection. You should keep a record of all information (including copies of letters) supplied to or from the company, for the purpose of entering into this contract. A copy of this proposal form will be supplied to the policyholder on request within three months of completion. PArt B - Declaration If you have not given full and true answers to all questions asked on this Proposal, your insurance cover may not protect you in the event of a claim. You should disclose all material facts as failure to do so could invalidate the policy. A material fact is information which is likely to influence an insurer in the assessment and acceptance of a risk. You must disclose all material facts about yourself, any other drivers, the vehicle and it s use that is known to you at the time of applying for this insurance. If you have any doubt as to whether a fact is material or not then please disclose it now, to avoid any chance of invalidating the policy. 10
11 Claims and Underwriting Exchange Register Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Database Services Ltd (IDS Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. When you tell us about an incident we will pass information relating to it, to the register. Your policy details will be added to the Motor Insurance Database (MID), run by the Motor Insurers Information Centre (MIIC). This may be consulted by: a) the Police for the purposes of establishing whether a driver s use of the vehicle is likely to be covered by a motor insurance policy and/or for preventing and detecting crime b) other UK insurers, the Motor Insurers Bureau and MIIC may search the MID to ascertain relevant policy information if you have been involved in an accident in the UK or abroad c) the DVLA and DVLNI for the purposes of Electronic Vehicle Licensing d) Persons pursuing a claim in respect of a motor traffic accident (including citizens of other countries) may also obtain relevant information which is held on the MID You should show this notice to anyone insured to drive the vehicle(s) under this policy. You can find out more about the Motor Insurance Database and it s use by contacting AXA Insurance UK plc or at Data Protection Act AXA Insurance UK plc is a member of the AXA Group. In order to supply your quotation and then to set up and administer your insurance policy we will hold and use information including sensitive personal data (such as criminal convictions and health information) you have provided and may send it in confidence for secure processing to other companies in the AXA Group (or companies acting on our instructions ) including those located outside the European Economic Area. AXA Insurance UK plc may occasionally contact you with details of our other products and services. If you do not wish to receive this information from AXA Insurance UK plc, Tick this box We may provide information supplied by you to selected third parties who may contact you in relation to the provision of insurance related services. If you do not wish us to provide your information to third parties, tick this box. Before signing the Declaration, please read the notices on this page about the Claims and Underwriting Exchange Register and Data Protection Act. Declaration Please read the Declaration carefully and then sign below. If there is more than one Proposer both should sign. I/We declare that we have included all material facts as requested within this Proposal. I/We declare that the answers given to questions asked in this Proposal are true and complete to the best of my/our knowledge and belief. I/We understand that any material fact, which is information that may influence the Company in the acceptance of this insurance and the terms provided has been disclosed and recorded. I/We understand that you will pass the information on this form and about any incident I/We may give details of to IDS Ltd, ABI and MIIC so that they can make it available to other insurers. I/We also understand that, in response to any searches you may make in connection with this application or any incident I/We have given details of, IDS Ltd and ABI may pass you information it has received from other insurers about other incidents anyone insured to drive the vehicle covered under the Policy have been involved in. I/We agree to accept the terms and conditions contained in the AXA Insurance UK plc Policy applying to this Proposal. Signature of Proposer Date Liability does not commence until an official cover note has been issued 11
12 AXA is a world leader in wealth management and financial protection. We operate in over 0 countries and serve more than 0 million customers worldwide. We cater to a wide range of needs, providing guidance to our individual and corporate customers on a variety of financial products and services. In addition to Business, Motor and Home Insurance we also offer Investments, Life Assurance, Retirement Planning, Long Term Care, Asset Management, Medical Insurance and Dental Payment Plans. With our expertise and commitment to customer service and consistent, quality care, you can rely on axa for lasting security. ask about axa s excellent range of business, home and motor insurance ProduCts WMO22/X (10/06) (12) AXA Insurance UK plc Registered in England 0. Registered Office: Old Broad Street, London EC2N 1AD A member of the AXA Group of Companies. AXA Insurance UK plc is authorised and regulated by the Financial Services Authority. In order to maintain a quality service, telephone calls may be monitored or recorded.
MISCELLANEOUS AND SPECIAL TYPE VEHICLES. Motor Insurance Proposal May 2018 Edition
MISCELLANEOUS AND SPECIAL TYPE VEHICLES Motor Insurance Proposal May 2018 Edition Important Notice To apply for the Miscellaneous and Special Type Vehicles Insurance Policy, complete this Proposal Form
More informationHaulage Vehicle Insurance. Proposal Form September 2013 Edition
Haulage Vehicle Insurance Proposal Form September 2013 Edition Important Notice To apply for the Haulage Vehicle Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue
More informationHAULAGE VEHICLE INSURANCE. Proposal Form October 2016 Edition
HAULAGE VEHICLE INSURANCE Proposal Form October 2016 Edition Important Notice To apply for the Haulage Vehicle Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue
More informationMOTOR FLEET PROPOSAL FORM
MOTOR FLEET PROPOSAL FORM QBE Mill Court Mill Street Stafford ST16 2AX Tel: (0)845 602 0983 Fax: (0)845 602 0984 QBE European Operations is a trading name of QBE Insurance (Europe) Limited, no. 01761561
More informationPROPERTY DEVELOPMENT CONTINGENCY INSURANCE. Proposal Form November 2005 Edition
PROPERTY DEVELOPMENT CONTINGENCY INSURANCE Proposal Form vember 2005 Edition Important tice To apply for the Property Development Contingency Insurance Policy, complete this Proposal Form in BLOCK CAPITALS
More informationAddress. Number of Years Trading. Value Year of Make Claims Free Years. Make Model Registration Number / Serial Number
Important Information Please read the following carefully before you complete, sign and date this form: The answers you have given to these questions will usually provide us with sufficient information
More informationMOTOR TRADE ROAD RISKS ANNUAL DECLARATION COVER ENGINEERED FOR THE MOTOR TRADE
MOTOR TRADE ROAD RISKS ANNUAL DECLARATION COVER ENGINEERED FOR THE MOTOR TRADE Motor Trade Road Risks Important Note You are under a duty to make a fair presentation of the risk to us before the inception,
More informationMotor Trade Road Risks Proposal Form
Motor Trade Road Risks Proposal Form coveainsurance.co.uk Motor Trade Road Risks Proposal Form Important notes 1. You are reminded of the need to disclose any material facts, i.e. those that the Insurer
More informationMotor Fleet Proposal Form
Motor Fleet Proposal Form Important tes Material Facts Failure to disclose material facts could result in your policy being invalidated. Material facts are those facts which might influence the acceptance
More informationspecial types plant cover proposal
special types plant cover proposal special types proposal Your Personal Details Name Trading Name Full Address Postcode Occupation Company Type Drivers 1 Driving Restrictions Required Please provide all
More informationSELF DRIVE HIRE PROPOSAL FORM
Insurance Company Limited SELF DRIVE HIRE PROPOSAL FORM 7 Eastern Road, Romford, Essex RM1 3NH Tel 01708 678480 Fax 01708 678444 Email romford.sales@tradex.com www.tradex.com Office Hours: Monday-Friday
More informationHaulage factfinder. 1 of 8. Personal details: 1 General details: Risk Address: Postcode. Company Website address (if applicable):
February 2017 edition Haulage factfinder Personal details: Name of insured: (Individual or Company) Policy number (if applicable) Risk Address: Postcode Company Website address (if applicable): 1 General
More informationPrivate motor proposal form Please complete all questions on this form and tick the relevant boxes.
Private motor proposal form Please complete all questions on this form and tick the relevant boxes. 1. Personal details (a) Proposer s full name and title (Mr/Mrs/Miss/Ms) (b) Policy number (c) Postal
More informationProposer(s) Policy or cover note number. Inception date. Broker
HOMEFLEET PROPOSAL FORM Proposer(s) Policy or cover note number Inception date Broker Tradex Insurance Company Limited Victory House, 7 Selsdon Way, London E14 9GL T: 0845 373 1321 F: 020 7959 7530 Email:
More informationXS Direct Insurance Brokers Limited s Terms of Business
XS Direct Insurance Brokers Limited s Terms of Business 1. Name and Address. Regulatory Status Our legal name is XS Direct Insurance Brokers Limited and our registered office is 1 Merrion Place, Dublin
More informationFarm Motor Quote Request / Proposal Form
5 Park Plaza Knights Way Battlefield Shrewsbury SY1 3AF Tel: 01743 460555 e-mail: info@farmsure.co.uk Farm Motor Quote Request / Proposal Form Please complete this form clearly using BLOCK CAPITALS Broker
More informationtaxi fleet Fleets of three or more vehicles proposal
taxi fleet Fleets of three or more vehicles proposal taxi fleet proposal Your Personal Details Name in full (Mr/Mrs/Miss/Ms) Trading Name Telephone Number Are you VAT Registered YES NO Full Address Drivers
More informationPROPOSAL FOR MOTOR INSURANCE
PROPOSAL FOR MOTOR INSURANCE 1b Braemar Avenue, Kingston 10, Jamaica W.I Telephone: (876) 656-8000; Telefax: (876) 656-8001 Email: info@ironrockjamaica.com Visit: www.ironrockjamaica.com PROPOSER DETAILS
More informationProfessional Indemnity for the Motor Trade
Allianz Insurance plc www.allianz.co.uk Supplementary Proposal Form Professional Indemnity for the Motor Trade This is a supplementary proposal form and should be completed and read in conjunction with
More informationTradewise Insurance Company Limited Statement of Claim
Page 1 Tradewise Insurance Company Limited Statement of Claim Please remember that it is normal practice for an Insurer to fully investigate a claim. You must ensure that you are open and honest with your
More informationAviva Motor Policy Summary and Important Information
Aviva Motor Policy Summary and Important Information This is a summary of the policy and does not contain the full terms and conditions of the cover which can be found in the policy documentation. It is
More informationCOMMERCIAL VEHICLE FIRE AND THEFT REPORT FORM
Tradewise Insurance Services Ltd COMMERCIAL VEHICLE FIRE AND THEFT REPORT FORM 300 Southbury Road, Enfield, Middlesex EN1 1TS Tel: 0344 620 1234 Claims Department Fax: 020 8350 2350 Driving entitlement
More informationVan Insurance Summary of cover
Van Insurance Summary of cover About this document This document is a summary of the insurance provided by our Van insurance policy. Therefore it does not contain the full terms and conditions of your
More informationTAXI PROPOSAL FORM. Proposer(s) Company or trading name if different. Policy or cover note number. Inception date. Broker or agent
TAXI PROPOSAL FORM Proposer(s) Company or trading name if different Policy or cover note number Inception date Broker or agent Tradex Insurance Company Limited Victory House, 7 Selsdon Way, London E14
More informationFordInsure. Driveaway with Ford Insure and get 7 days cover FREE
FordInsure Driveaway with Ford Insure and get 7 days cover FREE 1 Driveaway with FordInsure and get 7 days cover FREE The day you ve been waiting for has arrived and your new Ford is ready for collection.
More informationMOTOR TRADE ROAD RISKS FIRE AND THEFT REPORT FORM
Tradewise Insurance Services Ltd MOTOR TRADE ROAD RISKS FIRE AND THEFT REPORT FORM 300 Southbury Road, Enfield, Middlesex EN1 1TS Tel: 0344 620 1234 Claims Department Fax: 020 8350 2350 Driving entitlement
More informationProperty Claim Form.
Property Claim Form www.aiua.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent to us. We would therefore ask you
More informationPublic / Employer Liability Claim Form
Public / Employer Liability Claim Form www.aiua.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent to us. We would
More informationImportant information about your policy
Important information about your policy Inside you ll find details of changes to your Tesco Bank Car Insurance policy Car Insurance 1 Changes to your Tesco Bank Car insurance policy There are some changes
More informationMotor Accident Report Form
Completing the claim form It is always important to notify your Insurer of a claim as soon as possible after an accident has occurred. Please therefore complete this form and return it to us within 14
More informationPROPOSAL FOR MOTOR PRIVATE
GA Insurance House, Ralph Bunche Road, P O Box 42166-00100 Nairobi, Kenya. Telephone: 2711633 Fax 2714542 E-mail: insure@gakenya.com PROPOSAL FOR MOTOR PRIVATE AGENT: POLICY NO. FULL NAME... AGE E-MAIL..
More informationSwiftcover Van Insurance
Swiftcover Van Insurance Summary of cover About this document This document is a summary of the insurance provided by our van insurance policy and as such it does not contain the full terms and conditions
More informationProposal Form. Tradesmen. Commercial Division
Proposal Form Tradesmen Commercial Division Tradesmen Policy A Policy designed to meet the needs of smaller contractors with up to 10 persons (employees and labour only sub-contractors) working manually
More informationMotor Vehicle Insurance claim
Motor Vehicle Insurance claim The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form, unless specifically arranged
More informationABOUT OUR SERVICES AND COSTS
ABOUT OUR SERVICES AND COSTS 1. The Financial Conduct Authority (FCA) The FCA is the independent watchdog that regulates financial services. This document is designed to be given to consumers considering
More information1. Personal Information
small craft Proposal Form For crafts up to 5 metres (16 6 ) used for private pleasure purposes only Please complete in BLOCK CAPITALS throughout and tick or in the appropriate boxes. 1. Personal Information
More informationfor when your excuses run out
Group Cover Protect your business... ChauffeurPlan, for when your excuses run out The cost to your business... With 3 million drivers expected to be caught by speed cameras this year and over 6,000 speed
More informationMotor Vehicle Insurance Claim. Insured
GWS Network 14 Harvey Street Richmond Victoria Australia 3121 t: 03 8420 8700 f: 03 8420 8777 e: admin@gwsins.com w: www.gwsins.com ABN: 20 000 669 778 AFS licence: 231210 Motor Vehicle Insurance Claim
More information1 of 8. Who can use this proposal form. Checking the form. Copies of documents. Law applicable to the policy
Management Liability Policy for Residential Property Management Associations and Residential Management Companies Standard proposal form (with premiums) Who can use this proposal form This proposal form
More informationAviva Motor Policy Summary and Important Information
Aviva Motor Policy Summary and Important Information This is a summary of the policy and does not contain the full terms and conditions of the cover which can be found in the policy documentation. It is
More informationMOTOR TRADE ROAD RISKS ACCIDENT REPORT FORM
Tradewise Insurance Services Ltd MOTOR TRADE ROAD RISKS ACCIDENT REPORT FORM 300 Southbury Road Enfield, Middlesex EN1 1TS Tel: 0344 620 1234 Claims Department Fax: 020 8350 2350 Driving entitlement consent
More informationDance Teachers Insurance
Dance Teachers Insurance Policy information and proposal form Imperial Society of Teachers of Dancing Insurance scheme available to members and authorised personnel based in the UK Policy information As
More informationProvident Thirty Plus
Provident Thirty Plus This is a Policy Summary only and does not contain the full terms and conditions of your insurance contract; these can be found in your Policy Booklet. A copy of the Policy Booklet
More informationMotor Vehicle Insurance Application
Dawes Motor Insurance Motor Vehicle Insurance Application www.dawes.com.au IMPORTANT NOTICES Your PDS This contract of insurance is arranged by Dawes Underwriting Australia Pty Ltd trading as Dawes Motor
More informationPersonal Cover Protect your lifestyle... ChauffeurPlan, for when your excuses run out
Personal Cover Protect your lifestyle... ChauffeurPlan, for when your excuses run out Don't take your licence for granted, it could be gone in a FLASH! With 3 million drivers expected to be caught by speed
More informationDriveline Transport Package Proposal
Global Transport & Automotive Insurance Solutions Pty Limited ABN 93 069 048 255 AFSL: 240 714 Level 6, 55 Chandos Street St Leonards 2065 PO Box 507 St Leonards 1590 Phone 02 9966 8820 Fax 02 9966 8840
More informationHOME CONTENTS INSURANCE Designed Exclusively for Residents of:
HOME CONTENTS INSURANCE Designed Exclusively for Residents of: Aon UK Limited, Tenant Insurance Services, are offering YOU the chance to apply for low cost Home CONTENTS Insurance THIS COVER CONSISTS OF
More informationApplication and income payment form B.
Annuities Application and income payment form A Below Standard Lifetime Allowance Please use black ink and write in CAPITAL LETTERS or tick 4 as appropriate. Any corrections must be initialled. Please
More informationMOTOR ACCIDENT & THEFT CLAIM FORM
MOTOR ACCIDENT & THEFT CLAIM FORM Please do not obtain any quotations. We will appoint an Assessor to assess the damage to your vehicle. Clear copy of Driver s licence to be submitted with claim form.
More informationHomeCover Application
Form Allianz Insurance plc www.allianz.co.uk HomeCover Application Home Agent Details Agent Policy No. KF / Account No. / / Premium Instalment Agreement No. DA / Important Information for Applicants: This
More informationMotor Vehicle Claim Form
MOTOR VEHICLE Allianz Australia Insurance Limited CLAIM FORM McKenna Hampton Pty Ltd "Kandahar House" Level 1, 41-43 Ord Street West Perth WA 6005 Motor Vehicle Claim Form PO Box 204, West Perth WA 6872
More information2. Have you ever traded under a different name? YES NO If YES, please advise details:
CONTRACTORS ALL RISKS PROPOSAL FORM Please answer all questions, completing the form in ink using block capitals. The completion and signature of this Proposal does not bind the Proposer or Insurers to
More informationTokioMarine HCC Specialty Group
Specialty Group 1 Aldgate London EC3N 1RE, United Kingdom Tel: +44 (0)20 7648 1100 TokioMarine HCC Specialty Group Key Man Proposal Form Tokio Marine HCC - Specialty Group is a trading name of HCC Specialty
More informationMotor Vehicle Insurance Proposal
Motor Vehicle Insurance Proposal Important Notices Please read this section before completing this Proposal. Definitions Excess Excesses apply to all sections of Your policy and are detailed in the Schedule
More informationMotor Vehicle Claim Form
Motor Vehicle Claim Form Claim Number 1. Insured Name of Insured Occupation Contact Person Telephone No. Home No. Business No. Mobile Email Broker/Agent Name Telephone No. Policy No. Excess $ Inception
More informationMOTOR TRADE CLAIM FORM
MOTOR TRADE CLAIM FORM Policyholder s Name Company Name Policy No. Cover Applicable Comprehensive Third Party Fire & Theft Third party only Broker/Agent (if applicable) IMPORTANT We wish to process your
More informationAPPLICATION FOR DRIVER APPROVAL
Intermediary APPLICATION FOR DRIVER APPROVAL Intermediary. SECTION 1: COMPANY DETAILS Company/Policyholder name: Address: State: Postcode: Phone number: COMPLETING THIS FORM: This form is designed to allow
More informationApplication Form for Professional Indemnity and Liability Insurances Management Consultants
Application Form for Professional Indemnity and Liability Insurances Management Consultants This application form must be completed signed and dated by your Principal, Director or Partner Please ensure
More informationNeed to make a claim? Motor Legal Protection Cover
Need to make a claim? 03300 240 242 Motor Legal Protection Cover. About your cover This is your Motor Legal Protection policy. This cover will run alongside your car insurance policy, provided by Provident
More informationmotor trade road risks cover proposal
motor trade road risks cover proposal motor trade proposal Important This proposal has been completed in conjunction with the risk presentation provided by your insurance intermediary. The information
More informationWhat happens if you get too many points on your licence...?
What happens if you get too many points on your licence...? B A N N E D!...or you are disqualified? The Answer? You could receive up to 30,000 * to spend on alternative travel arrangements. 2 Up to a maximum
More informationApplication Form for Professional Indemnity and Liability Insurances Medical & Scientific Consultants
Application Form for Professional Indemnity and Liability Insurances Medical & Scientific Consultants This application form must be completed signed and dated by your Principal, Director or Partner Please
More informationSecure Boat Claim form
Secure Boat Claim form Notes: The issue of this Claim Form is not an admission of liability on our part. All questions must be fully answered in either black or blue pen. Please print clearly and tick
More informationLivestock Claim Form.
Livestock Claim Form www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent to us. We would
More informationHousing Application Form
Housing Application Form Please read this form carefully and fill in details for you and the joint applicant if there is one (a joint applicant is an adult applying for a joint tenancy with you). Fill
More informationProposer Details. Application Form for Professional Indemnity and Liability Insurances Surveyors
Application Form for Professional Indemnity and Liability Insurances Surveyors This application form must be completed signed and dated by your Principal, Director or Partner Please ensure that all questions
More informationHome insurance application form
CLEAR Choice Home insurance application form Policy/Quote Reference Number: Date Cover to commence: A copy of the completed application form is available on request but you should keep a record of all
More informationSummary of Cover. An insurance package for your business suitable for: Why choose the AXA Haulage Vehicle Insurance? Haulage Vehicle Insurance
Haulage Vehicle Insurance Summary of Cover An insurance package for your business suitable for: Hauliers operating up to 5 vehicles within the UK. Hauliers where all drivers are over the age of 25 and
More informationINSURANCE PROPOSAL FORM
YACHTMASTER INSURANCE SERVICES LIMITED. Ferry Quay House, Ferry Quay, Woodbridge, Suffolk. IP12 1BW. Tel. 01394 615755. Fax 01394 615735. E-mail enquiries@yachtmasterinsurance.co.uk Authorised and regulated
More informationAGRICULTURAL VEHICLE INSURANCE
AGRICULTURAL VEHICLE INSURANCE Your Policy Terms and Conditions August 2016 Edition CONTENTS Agricultural Vehicle Insurance Contents Your Policy 3 Important telephone numbers 3 Definitions 4 Policy Cover
More informationSurname Other Names Mr,Mrs,Miss,Ms Address
MOTOR VEHICLE CLAIM FORM The Issue of this Form is not an Admission of Liability by Insurers Policy # : Claim # : We understand the difficulties arising from your accident. Please complete and return this
More informationRecruitment Application Form and Equal Opportunities Monitoring Form
Recruitment Application Form and Equal Opportunities Monitoring Form Please complete Position applying for: Salary required: per annum or per hour Available to take up employment: (date of length of notice
More informationapplication form NURSERIES INSURANCE Version 4
application form NURSERIES INSURANCE Version 4 NURSERIES INSURANCE APPLICATION FORM 3 To the Ecclesiastical Insurance Office plc, Beaufort House, Brunswick Road, Gloucester GL1 1JZ. Answers to the following
More informationClaim Form Hospitalisation
Claim Form Hospitalisation ACE European Group Limited, A Chubb Company Claims Department PO Box 682 Winchester SO23 5AG T: 0345 841 0059 F: 0141 285 2901 claims@chubb.com Please write in black ink and
More informationTerms and conditions for the ŠKODA Real Life Test Drive
Terms and conditions for the ŠKODA Real Life Test Drive 1 ŠKODA Real Life Test Drive offer ( Test Drive Promotion ) 1.1 2 demonstration vehicles, an Octavia Estate SE L and a Superb Hatch L&K (The Car)
More informationMotor Fleet Haulage. fact finder 6TH FLOOR ONE AMERICA SQUARE 17 CROSSWALL LONDON EC3N 2LB TELEPHONE
Please fill out this form using the latest version of adobe reader Download the latest version here: http://get.adobe.com/uk/reader/ Motor Fleet Haulage TELEPHONE 020 7977 4800 WWW.LONDONMARKETBROKING.CO.UK
More informationBusiness Package Proposal Form INSURANCE
Business Package Proposal Form INSURANCE INDEX SECTION NOS. PAGES 1 Fire 1 2 Business Interruption 2 3 3 All Risks 3 4 Theft 4 5 Money 4 6 Glass 5 7 Goods in Transit 5 8 Liability 5 9 Motor 7 AGENT AND
More informationYour Motor Policy. Masterpiece
Your Motor Policy Masterpiece This document gives you key information about the Chubb Masterpiece Motor Insurance Policy. Please read our policy booklet for full terms and conditions. Please contact your
More informationADDING OR AMENDING CONTRIBUTIONS ON YOUR INITIAL PRICE PERSONAL PENSION (PP5)
Financial adviser stamp ADDING OR AMENDING CONTRIBUTIONS ON YOUR INITIAL PRICE PERSONAL PENSION (PP5) Financial adviser agency number Please enter your business postcode Are you enclosing a cheque with
More informationComputer Cyber Insurance
Computer Cyber Insurance Proposal form Computer, data and cyber-risks insurance Please answer all of the following questions carefully, providing any additional information that is needed, continue on
More informationClaim Form GROUP PTY LTD. RSM GROUP Pty Ltd - Wholesale Broking
GROUP PTY LTD Claim Form RSM GROUP Pty Ltd - Wholesale Broking ABN 40 006 361 226 AFS Licence No. 239631 380-382 Canterbury Road, Surrey Hills Vic 3127 Private Bag 4000 Surrey Hills Vic 3127 T: (03) 9276
More informationPersonal Portfolio Proposal Form
Personal Portfolio Proposal Form PERSONAL PORTFOLIO POLICY PROPOSAL FORM Please complete using block capitals throughout and tick the appropriate boxes clearly. It is important that every question is completed
More informationRequest to add an additional life/lives assured
Request to add an additional life/lives assured For use with the Premiere Europe Account and the Wealth Preservation Europe Account Warning: altering the lives assured on an existing policy is a chargeable
More informationIs your acceptance of the terms set out below and on the form; and
TERMS & CONDITIONS Please read these terms and conditions carefully and if there is anything you do not understand, please ask any member of staff. It is important that you fully understand and accept
More informationCLAIM FORM MOTOR VEHICLE- CARAVAN - TRAILER
MULTIPLE DISTRICT 201 of LIONS CLUBS INTERNATIONAL Inc. CLAIM FORM MOTOR VEHICLE- CARAVAN - TRAILER Instructions to the Club completing this Claim Form: 1. In the event of an incident leading to a Claim,
More informationclaim form home insurance Section 1 Details of policyholder Prior to submitting a claim
home insurance claim form Name Address Your insurance contract is underwritten by International Insurance Company of Hannover SE UK Branch, as referred to in the declaration at the end of this claim form
More informationClaim Form Personal Accident / Sickness
ACE European Group Limited, A Chubb Company Claims Department PO Box 682 Winchester SO23 5AG T: 0345 841 0059 F: 0141 285 2901 claims@chubb.com Claim Form Personal Accident / Sickness Please write in black
More informationUK Sickness claim form Please make sure...
UK Sickness claim form Please make sure... 1. 2. 3. 4. 5. 6. That you complete all the relevant sections and sign the claim form. That you carefully read, then sign and date, sections 6.2 and 6.4 (Access
More informationInsurance Policy Document. Motor Fleet MOTOR INSURANCE. Member of Canopius Group
Motor Fleet Insurance Policy Document MOTOR INSURANCE Member of Canopius Group You must read this document in conjunction with your policy schedule and Certificate of Insurance. If any information contained
More informationTERMS OF BUSINESS BETWEEN GAP INSURANCE TODAY AND THE POLICYHOLDER Terms and Conditions
TERMS OF BUSINESS BETWEEN GAP INSURANCE TODAY AND THE POLICYHOLDER Terms and Conditions These terms will apply to your use of our telephone services, whether or not you choose to take out insurance cover,
More informationMotor Vehicle Claim Form
Tokio Marine & Nichido Fire Insurance Co., Ltd. ABN 80 000 438 291 Managing Agent in Australia: Tokio Marine Management (Australasia) Pty. Ltd. ABN 69 001 488 455 Level 31, 9 Castlereagh Street, Sydney
More informationStatement of Fact for Your Self Employed Tradesman Policy. Policy Number 97SEP This is an important document and You must read it in full
Statement of Fact for Your Self Employed Tradesman Policy Policy Number 97SEP3169421 Produced on 14/06/2018 This is an important document and You must read it in full Policy Details Policy number The Policyholder
More informationPupil Transportation Policy
Name of School Corbets Tey School Policy Adopted Date 15/10/2015 Next Review Date 15/10/2016 Reviewed by Governors Name: Emma Marston Governors Signature: Pupil Transportation Policy Equality Impact Assessment
More informationThe A&A Group Ltd Commercial Vehicle Insurance Personal Accident Plan Policy Summary Insurer Period of Cover Policy Features & Benefits
The A&A Group Ltd Commercial Vehicle Insurance Personal Accident Plan Policy Summary This Policy Summary gives brief details of the Benefits and cover that are available as part of Your Commercial Vehicle
More informationEmployed Disability (Accident or Sickness) Claim Form
Employed Disability (Accident or Sickness) Claim Form Section A Your details (To be completed by you) Title Surname Forename(s) Address Home Telephone Number Alternative Telephone Number Email Address
More informationAddition Of A Power Of Attorney / Receiver / Deputy Application Form
OFFICE USE ONLY Customer Number for the Original Customer: Branch Code: Please complete this form in BLACK INK and using BLOCK CAPITALS. For further details on how to register an Attorney / Receiver /
More information1.8 Organisation details. Name
Claim form Please read our booklet Guide to making a Motor Insurers Bureau claim before you fill in this form. The booklet gives information about the MIB and how we deal with claims. l Please complete
More informationCancellation Expenses Claim Form
Please complete this claim fully and return to us by following the postal instructions below. Please return your completed form to: Staysure Trip Cancellation Claims PO Box 9 Mansfield Nottinghamshire
More informationREED INSURANCE LIMITED - CRITICAL ILLNESS CLAIM FORM REED REWARDS MEMBER
REED INSURANCE LIMITED - CRITICAL ILLNESS CLAIM FORM REED REWARDS MEMBER Instructions Please answer all questions accurately with full disclosure of all relevant information. Please return the completed
More informationLIABILITY CLAIM GUIDANCE NOTES
LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of claims made against you by any third party, for damage
More information