PRIVATE CAR PROPOSAL FORM PROPOSER`S FULL NAME

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PRIVATE CAR PROPOSAL FORM
PROPOSER'S FULL NAME: (Block Letters and State Mr., Miss, Mrs.)
Date of Birth:
OCCUPATION or PROFESSION:
POSTAL ADDRESS (Block Letters):
Name of Employer
Make and Model of Car
HP or C.C
Year of Manufacture
Type of Body and Seating Capacity
Price Paid by Proposer
Year of Purchase
Engine No.
Proposer's Estimated Value
Registration Number
PLEASE GIVE A PRECISE REPLY TO EACH OF THE FOLLOWING. TICKS AND DASHES CANNOT BE ACCEPTED AS
ANSWERS.
1. State fully the purposes for which the car will be used (The purposes
for which a car is used to be described on the Certificate of Insurance.
It is therefore essential that they are stated fully and accurately here.)
2. Has any alteration or addition been made to the Manufacturer's
standard engine design or specifications?
3. Is the Insurance to be restricted to the Car being driven solely by
you?
4. Is the car:
(a) registered in your name?
(b) owned SOLELY by you? If not, give names of other persons
(c) the subject of a Hire Purchase Agreement? If so, state Finance Company.
5. Do you suffer from defective vision or hearing or from any physical infirmity?
6. How long have you been driving Motor Vehicles continuously?
When was your driving licence first issued?
State class of licence
7. Have you ever been convicted of any offence(s) in connection with any more vehicle(s) or is prosecution pending? If
so, give full details of every such conviction and prosecution.
8. State Company or Underwriter with whom
you have been previously insured, in respect
of any motor vehicle (s)
(if not previously insured, state how driving
experience obtained)
9. Are you entitled to a No Claim Bonus from
your previous Insurers in respect of any of
the cars described in this proposal? If so,
please attach renewal notice
10. Has any Company or Underwriter ever
declined, cancelled or refused to renew your
Motor Insurance or imposed special terms?
If so give full details.
11. Have you had any accidents or losses during the last five years in connection with this or any other Motor Vehicle owned or
driven by you? If so, give particulars
Year of Total No. of
Accident Accidents
or Losses
Damage to Motor Vehicles Claims by Third Parties for
owned or driven by Proposer damage, injury or death
No.
Amount
No.
Amount
No.
Other
Amount
Paid
Outstanding
Paid
Outstanding
Paid
Outstanding
12. Please state whether you wish to insure under:(1) Comprehensive Policy?
(2) Third Party, Fire and Theft Policy?
(3) Third Party Policy only?
13. If a Comprehensive Policy is required , are the
following Perils to be included:(1) Flood, Hurricane, Earthquake?
(2) Strike, Riot & Civil Commotion?
14. Give particulars in the panel below of ANY OTHER PERSON(S) who to your knowledge, is/are likely to drive the car.
(THIS PART MUST BE COMPLETED IF THE ANSWER TO QUESTION 3 IS 'NO')
(a) FULL NAME
(State Mr. , Mrs, Miss)
(b) Postal Address
(c) Age
(d) Occupation
(e) State if suffering
from defective vision
or hearing or from
any physical infirmity
(f) State (I) how long
full licence to drive in
Barbados has been
held
(II) how long regularly
driving motor cars in
Barbados
(g) State if ever
convicted of any
offences in
connection with any
motor vehicle(s) or if
any prosecution
pending . Give full
details of every such
conviction and
prosecution
(h) State Company or
Underwriter with
whom previously
insured in respect of
any motor vehicle(s)
(i) State if any
Company or
Underwriter has ever
declined, cancelled or
refused to renew the
insurance of any
Motor Vehicle or
imposed special terms
(j) State if involved in
any accident whilst
driving any motor
vehicle during the last
three years
DECLARATION
I/We warrant that the above statements and particulars which I/We have read over and checked are true, that I/We have not
suppressed or mis-stated any material fact and that the Vehicle (or Vehicles) above referred to is/are in good condition and
repair. I/We desire to effect an insurance policy with the Insurance Corporation of Barbados Limited (ICBL) in terms, conditions
and exceptions of the policy to be issued by the company. I/We agree that this proposal shall form the basis of the contract
between me/us and the company and will be deemed as incorporated in the Policy to be issued. I/We further declare and agree
that if the above statements and particulars have been filled in by any person other than the undersigned, such person shall be
deemed to be my/our agent for the purpose of filling in this proposal form.
Dated this _________________ day of _____________________
FOR
OFFICE Policy No.
USE
ONLY Certificate No.
Inception Date:
Renewal Date:
Proposer's Signature: ________________________
1st Premium:
Renewal Premium: