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Private Motor Proposal

  • POLICY NUMBER:CERTIFICATE NUMBER:
  • HOME:WORK:CELL:
  • TERM OF INSURANCE FORFROMTO
  • Registered Letters and NumbersMake of Vehicle & Type of Body & ColourH.P. or C.C.Year of ManufactureSeating Capacity (including driver)Proposer’s Estimate of Present Value of Vehicle (including Accessories thereon) 
  • CHASIS:ENGINE NO:
  • 1. a) Will Vehicle be used solely for social, domestic and pleasurable purposes?b) If not, state for what purpose will it be used.i) By you for Professional purposes?ii) By you personally in connection with your own or your employer’s business?iii) By employees or other parties in connection with your own or your employer’s businessiv) For the carriage of samples or trade goods or farm requisites, produce or live-stock.c) For any other purpose
  • 2. a) State address where the Motor Vehicle is usually garaged.b) Is it garaged in the open?c) Is the garage locked?
  • 3. a) Date of purchase of Vehicle by you and from whom purchased?b) Whether new or second hand.c) Whether the engine or body has been modified from the Manufacturer’s standard specifications?d) Whether Vehicle has been wrecked or damaged before?e) Price Paid
  • 4. a) Owner of Vehicleb) Person in whose name vehicle is registeredc)Any finance company or other person financially interested in the vehicle 
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  • a) How long have you been continuously driving a vehicle with a valid driver’s license?b) Whether you had any motor vehicle accidents during the past 5 yearsc) Whether you had been charged and/or convicted of any offence in connection with the driving of any motor vehicle during the past 5 years.
  • 9. a) Are you now or have you been insured in respect of this Motor Vehicle? Or any other vehicle?b) If so, please state the name of the Insurance Company.c) Are you entitled to a No Claim Discount?d) Indicate the Policy numbere) What percentage?
  • COMPANYYEAR 
  • i) Declined your proposal?ii) Required you to bear the first portion of any loss or imposed other special condition?iii) Required an increased premium?iv) Refused to renew or cancelled your policy?
  • YearTotal Number of Motor Vehicles Owned By ProposerTotal Number of Accidents and Losses
  • Paid (No.)Paid (Amount)Outstanding (No.)Outstanding (Amount.)
  • Paid (No.)Paid (Amount)Outstanding (No.)Outstanding (Amount.)
  • NAMEAGEDRIVING EXPERIENCERELATION TO PROPOSERNUMBER OF ACCIDENTS DURING THE PAST 5 YRS 
  • I/We desire to insure with GENERAL INSURANCE COMPANY LIMITED the motor vehicle/vehicles described in the above Proposal and I/We hereby warrant that the above statements and particulars are true and I/We have not suppressed misrepresented or misstated any material fact and I/We agree that the declaration shall be the basis of the contract between me/us and the Company. I/We further agree that if this proposal in any particular is filled in by you or any other person such person shall be deemed my/our agent and not the agent of the Company. I/We further declare that I/We have read and understood all particulars entered herein and I/We have signed this after verifying the same to be true and complete in all respects. I/We further declare that I/We am/are willing to accept the Company’s policy subject to the following clauses and warranties;
  • a) The person driving the vehicle is under 25 years; or b) Holds a valid provisional licence or c) Holds a valid licence but has been driving for less than (2) years.
  • Dated ThisDate OfYearPlace
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  • NO INSURANCE IS IN FORCE UNTIL THE FULL PREMIUM HAS BEEN PAID AND THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY, WHICH RESERVES THE RIGHT TO DECLINE ANY PROPOSAL
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