motor insurance proposal form

Citadel Insurance p.l.c. is a company authorised to carry on general and long term business of insurance and is regulated by the Malta Financial Services Authority.
You are to disclose all material facts. If you are in doubt about a particular fact you should disclose it. A material fact is any fact which is likely to influence the assessment and acceptance
of your proposal.
By signing this form, you confirm that you are giving your explicit consent, in terms
of the Data Protection Act, on behalf of yourself and all the other persons specified
in this form, for the Company to process your respective personal information as
outlined above and you confirm that you have brought this Data Protection Notice
to the attention of these other persons and obtained their respective consent. We
undertake to implement appropriate measures and safeguards for the purpose of
protecting the confidentiality, integrity and availability of all data processed.
You have the right to require that we provide you with access to your personal data
as well as the right to rectify, or, in appropriate circumstances, erase any inaccurate,
incomplete or immaterial personal data, which is being processed. However, you are
required to inform us immediately of any alterations relating to your personal data
which we are processing.
Every field on the form is mandatory. Should you fail to fill in any mandatory field, we
reserve the right to refuse insurance cover. Should any field be inapplicable to your
particular circumstances, please mark that field with the letters “N/A”.
Kindly inform us by ticking the box on the last page should you not want to
receive any direct marketing in terms of paragraph 8.
Should you have availed yourself of the services of one of our agents or tied insurance
intermediaries you confirm that you are aware that such agents and tied insurance
intermediaries will process your personal data pursuant to their legal obligations.
Relevant data will be disclosed or shared as appropriate with all our employees and
with our affiliated companies, associates, agents and tied insurance intermediaries,
your broker if any, the Malta Insurance Association, other insurance companies and
other third parties if pertinent to any of the purposes listed above including the
purpose listed in paragraph 8.
underwriting and issuing contracts of insurance, collecting premiums and 1.
submitting other bills, settling claims or paying other benefits, reinsurance, coinsurance and actuarial activities;
2. the proper performance of your contract of insurance;
3. underwriting of subsequent insurance applications/proposal forms which you may
lodge with the Company;
4. preventing, detecting and/or prosecuting fraud and any other criminal activity
which the Company is bound to report and meeting any other specific legal or
contractual obligations;
5. establishing, exercising or defending any legal action;
6. internal management, research and statistics, systems administration and the
development and improvement of our products and services;
7. the protection and promotion of our legitimate interests and the proper conduct
of our business;
8. informing you by direct marketing about our range of products and services
including those of our affiliated companies, associates, agents and tied insurance
intermediaries or other carefully selected organisations and companies.
2. DATA PROTECTION NOTICE
In terms of the Data Protection Act (Chapter 440 of the Laws of Malta), we will
process any personal and/or sensitive data supplied on/in this application/proposal
form or subsequently supplied by yourself, whether orally or in writing, for all or any
of the following purposes:
motor insurance proposal form
LIST OF ASSUMPTIONS
If your circumstances change between the date you purchase this Policy and the date when you require this Policy to commence, please call Us immediately. Incorrect information could
invalidate all or part of your motor insurance policy.
We assume that during the Period of Insurance:
1. Your car is registered as a ‘private vehicle’;
2. Your car is in a good state of repair;
3. You do not participate or intend to participate with Your car in racing, pace-making, hill climbs, quarter mile racing, speed testing or other similar events;
4. You do not carry any goods or materials in, on or with Your car including goods or materials of a hazardous nature (including, but not limited to, corrosive, toxic, poisonous, radioactive,
infectious, explosive or inflammable goods);
5. Your car will not be used for carriage of persons for hire or reward or as a private minibus;
6. Your car will not be used to visit hazardous locations (including, but not limited to, chemical/oil/gas/refineries, power stations, bulk storage or production premises in the explosive,
ammunition or pyrotechnic industries, military bases, airports/airside or in proximity to aircrafts).
By signing this proposal form You confirm these assumptions. If you are unable to confirm the above assumptions, please contact us.
THE PROPOSER
Address:
I do not consent to direct marketing
I/We have read and agreed to the Data Protection Notice, the Declaration, the
Important Notes and any other information relating to my/our rights. If there is more
than one proposer, then all persons must sign.
hard copy
e-mail
Please specify the format in which you prefer your copy of the Policy Document
electronic (cd)
/
MM
YYYY
/
NAME AND SURNAME OF PROPOSER(S) (BLOCK LETTERS):
DD
SIGNATURE OF PROPOSER(S):
DATE:
NAME AND SURNAME OF INTERMEDIARY:
www.citadeldirect.com
Citadel Insurance p.l.c.• Casa Borgo • 26 Market Street • Floriana FRN 1082
Customer Services Office • 28 St Anne Street • Floriana FRN 9011
Tel: 2557 9000 • Fax: 2557 9550 • Freephone: 8007 2322
Year of manufacture:
Make and model:
Engine number:
Type of body:
Number of passengers:
Current Mileage (kms):
Chassis number:
Engine capacity:
Number of
previous owners:
Colour:
N/A:
motor insurance proposal form
limited mileage
Registration number:
/
/ Date of Purchase:
/
/ Date of last VRT:
Proposer’s estimate of present
value including accessories:
Price paid:
/
/ Date of first registration:
CO2 (g/km):
Electric
Hybrid
Diesel
Petrol
Turbo
Brake horse power (bhp):
E-mail:
Mobile:
Tel. No:
I.D. No/Passport No:
Place of Birth:
Date of Birth:
Left hand drive:
Right hand drive:
Is your car:
Client Account No.:
Name:
3. Important Notes
1. You are advised to keep a copy of this Proposal Form for your records.
2. Only the Policy Document provides full details of what is and what is not covered.
A specimen policy is available on request.
3. We will provide you with a copy of the completed Proposal Form when ever you
require. Furthermore, we will undertake not to raise an issue under your Proposal
Form unless we first provide you with a copy of the Proposal Form which you had
submitted to us.
4. The Company is bound by the Professional Secrecy Act, 1994 with respect to
information furnished by you to Citadel Insurance p.l.c. in connection with this
insurance proposal. However, the Insurance Business Act, 1998 provides for the
exchange of such information with any other insurance company, insurance
intermediary and/or the Police solely for the purpose of preventing, detecting or
suppressing insurance fraud.
To keep the number of questions We ask you in this proposal form to a minimum, We make some assumptions about Your car and the use thereof. Please ensure that FIRST you read the
checklist below as it will form part of your motor insurance policy.
Limited Mileage Motor Proposal Form 01/11
Occupation:
THE CAR
1. (a) Was the car purchased overseas?
Yes
No
(b) If the car has been acquired as second hand please state from whom it has been purchased:
7. Have you or any additional drivers been driving during the past 12 months?
2. Where is the car kept overnight?
ii. outside, but in your premises
Yes
No
Yes
No
If yes, give details:
If yes, give details:
4. Is the car in a good state of repair?
Yes
No
5. Is the car:
9. Have you or any additional drivers:
(a) Had an insurance proposal declined?
No
If not, give details:
Yes
No
(b) Owned solely by you?
If not, give details:
Yes
No
(c) The subject of a hire purchase agreement? If so, give details:
(b) Been required to carry an additional excess?
Yes
No
(c) Been required to pay an increased premium or had any special conditions imposed?
Yes
No
(d) Been refused renewal of an insurance policy?
Yes
No
(e) Had an insurance policy cancelled?
Yes
No
Yes
No
%
Would you like to transfer this no claim discount onto the car related to this proposal ?
Yes
No
7. How many times in a year do you use your car for overseas travel?
Yes
No
€115
€235
1.If you are 25 years or over and have chosen a private car comprehensive insurance policy do you wish to extend cover to include
an alternative car following loss or damage to your car?
Yes
No
2. If you are 25 years or over and you are entitled to 3rd year or 4th year no claims discount, and have chosen a private car policy, do
you wish to protect your no claims discount?
Yes
No
3. Do you wish to extend your private comprehensive policy to include cover for earthquake?
Yes
No
COVER AND PREMIUM OPTIONS
1. Period of insurance
2. Type of insurance required:
No
No
State “no claim discount” currently earned:
6. Do you have any other current policies with Citadel Insurance p.l.c? If yes, please give us your policy number:
Yes
Yes
10. Are you entitled to a “no claim discount” from your previous insurers in respect of the car in this proposal?
Yes
No
(a) Registered in your name? 8. Are you exempt from paying duty
on the car to be driven?
Yes
iii. elsewhere (please specify street / parking area)
(b) Has any spray or other material been applied to the body panels of the car for promotional or other similar purposes?
No
8. In respect of yourself and all additional drivers, give details of any physical infirmity, defective vision or hearing, or any other medical condition which may impair the ability
to drive.
3. (a) Has any alteration or addition (including accessories) been made to the manufacturer’s standard design or specification or is such an alteration contemplated?
Yes
If yes give details:
If yes, please specify from which country:
i. in a locked garage
6. Have you and all additional drivers been prosecuted or convicted of any offence or is any such prosecution pending?
If YES, state the amount of duty you are liable to pay
(included in the estimate of present value):
(ii) Date of purchase
(iii) Serial number
(iv) V
alue (please note that cover
will be limited to €350)
/
/
Comprehensive
to
/
/
Third party fire and theft
3. Do you want to increase the excess payable in respect of “Own Damage” by:
9. No entertainment cover will be in force unless the details requested in this section are provided. (Please also provide a copy of the relative receipt)
Non-factory fitted
Factory fitted
(a) Please specify details of entertainment equipment fitted in the car:
(b) If entertainment equipment is not factory fitted, an additional charge will apply. Please provide the following details:
(i) Make & model
from
None
/
/
€
OPTIONAL EXTENSIONS (An additional charge will apply)
THE DRIVERS
Please specify Authorised Drivers:
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING:
1. Limited to yourself only? (A discount will apply)
2. Limited to yourself and Spouse only? (A discount will apply).
3. Limited to named drivers? (Up to 4 named drivers including policyholder) Please specify below
Yes
No
Yes
No
Yes
No
GIVE THE FOLLOWING INFORMATION ABOUT ANY PERSON INCLUDING YOURSELF WHO MAY DRIVE
Name (Proposer)
Occupation
Date of Birth
I.D. card
Type of Licence
Period Held
i
1. DECLARATION
(i)I/We agree that the Cover under this Policy shall be deemed to be effective provided that during the Period of Insurance the level of mileage of my car does not exceed
3,500 kilometres (or 2,175 miles);
I/We also understand that in the event that during the Period of Insurance the maximum level of mileage specified above is exceeded, no Claim shall be processed by
Citadel insurance plc until:
a)I/We reimburse Citadel Insurance plc with the difference between the premium which I/we would have paid when purchasing a standard motor insurance cover
excluding the limited-mileage discount and the premium paid when purchasing the Limited-Mileage Policy and
b)
ii
iii
iv
I/We pay Citadel Insurance plc the applicable excess in accordance with the terms of the standard motor insurance policy.
(ii)I/We declare that the information given in this Proposal Form is to the best of my/our knowledge true, accurate and complete. Further, I/We agree that if my/our answers
are not in my/our handwriting and/or have been written by any other person on my/our behalf, then such person shall for that purpose be regarded as my/our agent. I/We
I.D. card number:
4. State name of person who will be the main user of the car:
further declare that no material fact has been withheld and I/We understand that failure to disclose a material fact may result in the contract being declared void and that
5. Has any person mentioned above had any accident/loss in connection with any motor vehicle in the last five years? If yes, give details:
Yes
No
a claim under the policy may not be paid. A material fact is one which is likely to influence Citadel Insurance p.l.c. in the best assessment and acceptance of
this proposal. The Proposal Form and Declaration will be considered the basis of the contract and will form part of the Policy. I/We understand that the cover under the
Date of Loss
Amount/Estimate of damages incurred
€
€
Description of accident/loss
Policy will not be operative until this Proposal Form has been accepted by Citadel Insurance p.l.c., the relative premium has been paid and received by Citadel Insurance
p.l.c.
1. (a) Was the car purchased overseas?
Yes
No
(b) If the car has been acquired as second hand please state from whom it has been purchased:
7. Have you or any additional drivers been driving during the past 12 months?
2. Where is the car kept overnight?
ii. outside, but in your premises
Yes
No
Yes
No
If yes, give details:
If yes, give details:
4. Is the car in a good state of repair?
Yes
No
5. Is the car:
9. Have you or any additional drivers:
(a) Had an insurance proposal declined?
No
If not, give details:
Yes
No
(b) Owned solely by you?
If not, give details:
Yes
No
(c) The subject of a hire purchase agreement? If so, give details:
(b) Been required to carry an additional excess?
Yes
No
(c) Been required to pay an increased premium or had any special conditions imposed?
Yes
No
(d) Been refused renewal of an insurance policy?
Yes
No
(e) Had an insurance policy cancelled?
Yes
No
Yes
No
%
Would you like to transfer this no claim discount onto the car related to this proposal ?
Yes
No
7. How many times in a year do you use your car for overseas travel?
Yes
No
€115
€235
1.If you are 25 years or over and have chosen a private car comprehensive insurance policy do you wish to extend cover to include
an alternative car following loss or damage to your car?
Yes
No
2. If you are 25 years or over and you are entitled to 3rd year or 4th year no claims discount, and have chosen a private car policy, do
you wish to protect your no claims discount?
Yes
No
3. Do you wish to extend your private comprehensive policy to include cover for earthquake?
Yes
No
COVER AND PREMIUM OPTIONS
1. Period of insurance
2. Type of insurance required:
No
No
State “no claim discount” currently earned:
6. Do you have any other current policies with Citadel Insurance p.l.c? If yes, please give us your policy number:
Yes
Yes
10. Are you entitled to a “no claim discount” from your previous insurers in respect of the car in this proposal?
Yes
No
(a) Registered in your name? 8. Are you exempt from paying duty
on the car to be driven?
Yes
iii. elsewhere (please specify street / parking area)
(b) Has any spray or other material been applied to the body panels of the car for promotional or other similar purposes?
No
8. In respect of yourself and all additional drivers, give details of any physical infirmity, defective vision or hearing, or any other medical condition which may impair the ability
to drive.
3. (a) Has any alteration or addition (including accessories) been made to the manufacturer’s standard design or specification or is such an alteration contemplated?
Yes
If yes give details:
If yes, please specify from which country:
i. in a locked garage
6. Have you and all additional drivers been prosecuted or convicted of any offence or is any such prosecution pending?
If YES, state the amount of duty you are liable to pay
(included in the estimate of present value):
(ii) Date of purchase
(iii) Serial number
(iv) V
alue (please note that cover
will be limited to €350)
/
/
Comprehensive
to
/
/
Third party fire and theft
3. Do you want to increase the excess payable in respect of “Own Damage” by:
9. No entertainment cover will be in force unless the details requested in this section are provided. (Please also provide a copy of the relative receipt)
Non-factory fitted
Factory fitted
(a) Please specify details of entertainment equipment fitted in the car:
(b) If entertainment equipment is not factory fitted, an additional charge will apply. Please provide the following details:
(i) Make & model
from
None
/
/
€
OPTIONAL EXTENSIONS (An additional charge will apply)
THE DRIVERS
Please specify Authorised Drivers:
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING:
1. Limited to yourself only? (A discount will apply)
2. Limited to yourself and Spouse only? (A discount will apply).
3. Limited to named drivers? (Up to 4 named drivers including policyholder) Please specify below
Yes
No
Yes
No
Yes
No
GIVE THE FOLLOWING INFORMATION ABOUT ANY PERSON INCLUDING YOURSELF WHO MAY DRIVE
Name (Proposer)
Occupation
Date of Birth
I.D. card
Type of Licence
Period Held
i
1. DECLARATION
(i)I/We agree that the Cover under this Policy shall be deemed to be effective provided that during the Period of Insurance the level of mileage of my car does not exceed
3,500 kilometres (or 2,175 miles);
I/We also understand that in the event that during the Period of Insurance the maximum level of mileage specified above is exceeded, no Claim shall be processed by
Citadel insurance plc until:
a)I/We reimburse Citadel Insurance plc with the difference between the premium which I/we would have paid when purchasing a standard motor insurance cover
excluding the limited-mileage discount and the premium paid when purchasing the Limited-Mileage Policy and
b)
ii
iii
iv
I/We pay Citadel Insurance plc the applicable excess in accordance with the terms of the standard motor insurance policy.
(ii)I/We declare that the information given in this Proposal Form is to the best of my/our knowledge true, accurate and complete. Further, I/We agree that if my/our answers
are not in my/our handwriting and/or have been written by any other person on my/our behalf, then such person shall for that purpose be regarded as my/our agent. I/We
I.D. card number:
4. State name of person who will be the main user of the car:
further declare that no material fact has been withheld and I/We understand that failure to disclose a material fact may result in the contract being declared void and that
5. Has any person mentioned above had any accident/loss in connection with any motor vehicle in the last five years? If yes, give details:
Yes
No
a claim under the policy may not be paid. A material fact is one which is likely to influence Citadel Insurance p.l.c. in the best assessment and acceptance of
this proposal. The Proposal Form and Declaration will be considered the basis of the contract and will form part of the Policy. I/We understand that the cover under the
Date of Loss
Amount/Estimate of damages incurred
€
€
Description of accident/loss
Policy will not be operative until this Proposal Form has been accepted by Citadel Insurance p.l.c., the relative premium has been paid and received by Citadel Insurance
p.l.c.
Citadel Insurance p.l.c. is a company authorised to carry on general and long term business of insurance and is regulated by the Malta Financial Services Authority.
You are to disclose all material facts. If you are in doubt about a particular fact you should disclose it. A material fact is any fact which is likely to influence the assessment and acceptance
of your proposal.
By signing this form, you confirm that you are giving your explicit consent, in terms
of the Data Protection Act, on behalf of yourself and all the other persons specified
in this form, for the Company to process your respective personal information as
outlined above and you confirm that you have brought this Data Protection Notice
to the attention of these other persons and obtained their respective consent. We
undertake to implement appropriate measures and safeguards for the purpose of
protecting the confidentiality, integrity and availability of all data processed.
You have the right to require that we provide you with access to your personal data
as well as the right to rectify, or, in appropriate circumstances, erase any inaccurate,
incomplete or immaterial personal data, which is being processed. However, you are
required to inform us immediately of any alterations relating to your personal data
which we are processing.
Every field on the form is mandatory. Should you fail to fill in any mandatory field, we
reserve the right to refuse insurance cover. Should any field be inapplicable to your
particular circumstances, please mark that field with the letters “N/A”.
Kindly inform us by ticking the box on the last page should you not want to
receive any direct marketing in terms of paragraph 8.
Should you have availed yourself of the services of one of our agents or tied insurance
intermediaries you confirm that you are aware that such agents and tied insurance
intermediaries will process your personal data pursuant to their legal obligations.
Relevant data will be disclosed or shared as appropriate with all our employees and
with our affiliated companies, associates, agents and tied insurance intermediaries,
your broker if any, the Malta Insurance Association, other insurance companies and
other third parties if pertinent to any of the purposes listed above including the
purpose listed in paragraph 8.
underwriting and issuing contracts of insurance, collecting premiums and 1.
submitting other bills, settling claims or paying other benefits, reinsurance, coinsurance and actuarial activities;
2. the proper performance of your contract of insurance;
3. underwriting of subsequent insurance applications/proposal forms which you may
lodge with the Company;
4. preventing, detecting and/or prosecuting fraud and any other criminal activity
which the Company is bound to report and meeting any other specific legal or
contractual obligations;
5. establishing, exercising or defending any legal action;
6. internal management, research and statistics, systems administration and the
development and improvement of our products and services;
7. the protection and promotion of our legitimate interests and the proper conduct
of our business;
8. informing you by direct marketing about our range of products and services
including those of our affiliated companies, associates, agents and tied insurance
intermediaries or other carefully selected organisations and companies.
2. DATA PROTECTION NOTICE
In terms of the Data Protection Act (Chapter 440 of the Laws of Malta), we will
process any personal and/or sensitive data supplied on/in this application/proposal
form or subsequently supplied by yourself, whether orally or in writing, for all or any
of the following purposes:
motor insurance proposal form
LIST OF ASSUMPTIONS
If your circumstances change between the date you purchase this Policy and the date when you require this Policy to commence, please call Us immediately. Incorrect information could
invalidate all or part of your motor insurance policy.
We assume that during the Period of Insurance:
1. Your car is registered as a ‘private vehicle’;
2. Your car is in a good state of repair;
3. You do not participate or intend to participate with Your car in racing, pace-making, hill climbs, quarter mile racing, speed testing or other similar events;
4. You do not carry any goods or materials in, on or with Your car including goods or materials of a hazardous nature (including, but not limited to, corrosive, toxic, poisonous, radioactive,
infectious, explosive or inflammable goods);
5. Your car will not be used for carriage of persons for hire or reward or as a private minibus;
6. Your car will not be used to visit hazardous locations (including, but not limited to, chemical/oil/gas/refineries, power stations, bulk storage or production premises in the explosive,
ammunition or pyrotechnic industries, military bases, airports/airside or in proximity to aircrafts).
By signing this proposal form You confirm these assumptions. If you are unable to confirm the above assumptions, please contact us.
THE PROPOSER
Address:
I do not consent to direct marketing
I/We have read and agreed to the Data Protection Notice, the Declaration, the
Important Notes and any other information relating to my/our rights. If there is more
than one proposer, then all persons must sign.
hard copy
e-mail
Please specify the format in which you prefer your copy of the Policy Document
electronic (cd)
/
MM
YYYY
/
NAME AND SURNAME OF PROPOSER(S) (BLOCK LETTERS):
DD
SIGNATURE OF PROPOSER(S):
DATE:
NAME AND SURNAME OF INTERMEDIARY:
www.citadeldirect.com
Citadel Insurance p.l.c.• Casa Borgo • 26 Market Street • Floriana FRN 1082
Customer Services Office • 28 St Anne Street • Floriana FRN 9011
Tel: 2557 9000 • Fax: 2557 9550 • Freephone: 8007 2322
Year of manufacture:
Make and model:
Engine number:
Type of body:
Number of passengers:
Current Mileage (kms):
Chassis number:
Engine capacity:
Number of
previous owners:
Colour:
N/A:
motor insurance proposal form
limited mileage
Registration number:
/
/ Date of Purchase:
/
/ Date of last VRT:
Proposer’s estimate of present
value including accessories:
Price paid:
/
/ Date of first registration:
CO2 (g/km):
Electric
Hybrid
Diesel
Petrol
Turbo
Brake horse power (bhp):
E-mail:
Mobile:
Tel. No:
I.D. No/Passport No:
Place of Birth:
Date of Birth:
Left hand drive:
Right hand drive:
Is your car:
Client Account No.:
Name:
3. Important Notes
1. You are advised to keep a copy of this Proposal Form for your records.
2. Only the Policy Document provides full details of what is and what is not covered.
A specimen policy is available on request.
3. We will provide you with a copy of the completed Proposal Form when ever you
require. Furthermore, we will undertake not to raise an issue under your Proposal
Form unless we first provide you with a copy of the Proposal Form which you had
submitted to us.
4. The Company is bound by the Professional Secrecy Act, 1994 with respect to
information furnished by you to Citadel Insurance p.l.c. in connection with this
insurance proposal. However, the Insurance Business Act, 1998 provides for the
exchange of such information with any other insurance company, insurance
intermediary and/or the Police solely for the purpose of preventing, detecting or
suppressing insurance fraud.
To keep the number of questions We ask you in this proposal form to a minimum, We make some assumptions about Your car and the use thereof. Please ensure that FIRST you read the
checklist below as it will form part of your motor insurance policy.
Limited Mileage Motor Proposal Form 01/11
Occupation:
THE CAR