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 Surname First Name Middle Name Other Names/Alias Date of Birth Place of Birth Nationality Mother's Maiden name TRN Driver's License # Class Original Date Expiry Date ID Number / Type / Expiration Date Home Address (Street Number and Name) Town Parish/Country Mailing Address, if different from above (Street Number and Name) Town Parish/Country Home Number Work Number Mobile Number Email Address Source of Funds Occupation / Type of Business EMPLOYMENT DETAILS Title Employer Name Employer Telephone Number(s) Employer Address (Street Number and Name) Town Parish/Country Have you or any relative or close associate been entrusted with prominent public functions (e.g. Member of Parliament, Senate or Mayor, Senior Government Official, Judiciary, Security Forces)? Yes No If Yes, state the name, relationship and type of public office: If Yes to the above, please give the Name and Address of your spouse and children: Name Relationship Address Full Name Reference 1 Reference 2 Full Name Occupation Occupation Relationship Contact Relationship Contact IronRock Insurance Proposal For Motor Insurance (Rev 12/2018) 1 of 5
PARTICULARS OF VEHICLES TO BE INSURED Registration Make and Model Chassis & Engine Year of Make CC. Rating Seating Type of Body Sum Insured Are you the owner of the vehicle(s) and is/are it/they registered in your name? Yes No If not, state the name and address of the owner: Will a trailer be used? Yes No NOTE: You are required to ensure that the Sum Insured is revised annually to reflect the current market value. Claims will be settled based on the market value at the time of the loss. For total losses you will be paid based on the market value or Policy Sum Insured whichever is lesser. LIEN HOLDER Full Name Address (Street Number and Name, Town, and Parish/Country) Insurance Coverages Available: Select coverage required (tick the appropriate box): Comprehensive Liability for Third Party Bodily Injury and Property Damage and loss of or damage to the Insured s Motor Vehicle Third Party Fire & Theft Liability for Third Party Bodily Injury and Property Damage and Loss of or damage to the Insured s Insured s Motor Vehicle by Fire & Theft Third Party Liability for Third Party Bodily Injury and Property Damage Please indicate vehicle use: Carriage of own goods only (Private Commercial) Carriage of passengers not for hire or reward Carriage of passengers for hire or reward General Cartage (Public Commercial) Social domestic & pleasure purposes only Social domestic & pleasure purposes and Proposer s business use Commercial travelling Is the vehicle fitted with an anti-theft device? Yes No If yes, state the name, type of device and name of provider: Will you have regular custody of the vehicle? Yes No If not, please provide details: IronRock Insurance Proposal For Motor Insurance (Rev 12/2018) 2 of 5
Is the vehicle garaged at the Proposer s home address? If not, please state where: Yes No Is the vehicle kept in: A locked garage A locked area Other: Is the Proposer now insured or was previously insured in respect of any vehicle(s)? Yes No If yes, state the name and address of the Insurance Company: Is the Proposer entitled to No Claim Discount from previous insurer(s) in respect of any vehicle(s) described in the proposal? Yes No If yes, please attach proof of No Claim Discount Letter or Renewal Notice. Do you have any other insurance(s) with IronRock Insurance Company Ltd.? Yes No If yes, please state type(s): Has any Insurer(s) in respect of the Proposer or any other person who will regularly drive, ever: Declined your proposal? Yes No Required an increased premium or imposed special conditions? Yes No Cancelled or refused to renew an existing insurance? Yes No If yes, please give details below: Type of Authorized Driver Clause: Open Driving Insured Only (Discount Available) Insured plus One Insured plus Two Will anyone driving your motor vehicle: In respect of Private Cars: be under the age of 21 years old? Y N have driving experience less than 24 months? Y N In respect of Private Commercial: be under the age of 23 years old? Y N have driving experience less than 36 months? Y N In respect of General Cartage: be under the age of 25 years old? Y N have driving experience less than 5 years? Y N If yes to the above, please give particulars of drivers: Name(s) Occupation(s) Date of Birth Driver's Licence Original Date of Issue Relationship to Proposer IronRock Insurance Proposal For Motor Insurance (Rev 12/2018) 3 of 5
Will you be the regular driver of the vehicle? Yes No Please provide details of the drivers likely to drive the motor vehicle: Name(s) Occupation(s) Date of Birth Driver's Licence Original Date of Issue Relationship to Proposer Have you or any regular drivers had any accidents or losses during the past three (3) years: Yes No Has any vehicle owned by you been involved in an accident in the last three (3) years? Yes No If yes, please give details below: Date of Accident Cost (Paid or Estimated) Driver Brief Details of Accident, Incident or Losses To the best of your knowledge and belief have you, or any person who to your knowledge will drive, have suffered or now suffer from: Defective vision or hearing? Yes No Diabetes, Epilepsy, complaints of the heart or any other disease? Yes No Any other physical or mental infirmity? Yes No Have you or any person who to your knowledge will drive received any traffic ticket(s) and or have been convicted of any offence in connection with the driving of any motor vehicle within the last three (3) years? Yes No Has the vehicle been modified or converted from makers standard specification or do you intend to do so? Yes No Do you require increased limits (in excess of the Standard Limits)? Yes No Standard Limits Increased Limit Options Protection and Removal (Wrecker Fee) 35,000 50,000 75,000 100,000 Medical Expenses (Including Passengers) 30,000 45,000 55,000 75,000 Manslaughter Defense Costs 250,000 300,000 400,000 500,000 Third Party Limits (Bodily Injury and Property Damage) Sums Insured < 2M 3M/5M/5M 5M/7.5M/5M 5M/10M/5M 10M/10M/10M Sums Insured 2M 5M/10M/5M 15M/15M/ 15M 10M/10M/10M IronRock Insurance Proposal For Motor Insurance (Rev 12/2018) 4 of 5
DUTY TO DISCLOSE. This proposal must be completed, dated and signed by the proposer. When answering the questions on this form, you must be honest and truthful. You have a duty under law to tell us anything known to you which is material to the questions asked as those answers will guide us in deciding whether to insure you or anyone else to be insured under the policy and on what terms. If you are in doubt as to whether a fact is relevant you should state it. Your duty to make full and frank disclosure occurs: (1) at the time of proposing for insurance (2) during the currency of the policy, if there are any changes or variation in the information given and (3) at each renewal. FAILURE TO DISCLOSE. If you do not comply with these duties and answer our questions honestly, the Company will be at liberty to treat your Policy as if it never existed and refuse to pay any claims you make under it. Disclaimer: The liability of the Company does not commence until the acceptance of the proposal has been formally acknowledged by the Company and a premium or deposit has been paid, except as provided by an Official Cover Note issued by the Company. I/We declare that the above answers are true and that all particulars affecting the assessment of the risk have been disclosed. I declare that the information given above has been verified by original documents to ensure the veracity of the information given. Proposer's/Agent's Signature / Date Joint Proposer's Signature / Date Customer Service Representative / Date THIS SECTION IS ONLY APPLICABLE IF AN AGENT IS COMPLETING THE FORM ON BEHALF OF THE CLIENT Agent's Last Name Agent's First Name Agent's Middle Name Nationality Address (Street Number and Name, Town, and Parish/Country) ID Number & Expiration Date ID Type (DL, PP, Nat ID, Other) Tax Registration Number NB: Please submit the following: - A Power of Attorney or a letter duly notarized. - Proof of Address - Picture identification (insured and agent, where applicable) - TRN (if a driver s licence is not being used) IronRock Insurance Proposal For Motor Insurance (Rev 12/2018) 5 of 5