Goods CarryinG VehiCle insurance Proposal Form vember 2006 Edition
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
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
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
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
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
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.
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?
(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
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
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 www.miic.org.uk. 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
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 www.axa.co.uk 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.