PROPOSAL FOR MOTOR INSURANCE - Colfire

Head Office: Corner Duke & Abercromby Street, Port of Spain, Trinidad W.I.
Telephone: (868) 623-2201-3/5 Fascimile: (868) 623-0925 E-mail: info@colfire.com Website: http://www.colfire.com
PERSONAL INFORMATION
PROPOSAL FOR MOTOR INSURANCE
(A copy of the policy is available on request)
Answer All questions, leaving no blanks, the form must be completed, dated and signed by the Proposer
1.
Name of Proposer (in full) - Mr./Mrs./Ms.
Nationality
Name of Proposer (in full) - Mr./Mrs./Ms.
Date of Birth:
(YYYY-MM-DD)
Nationality Date of Birth: (YYYY-MM-DD)
Or Name of Company:
2.
Driving Permit No: Class: Issue Date:
Expiry Date:
(YYYY-MM-DD)
Driving Permit No:
Class:
Issue Date:
Expiry Date:
(YYYY-MM-DD)
3.
Trade, Occupation, Profession:
Name of Employer:
Name of Employer:
Employer's Address:
Employer's Address:
Telephone No(s).:
Home:
Work:
Fax:
Cellular:
E-mail Address:
4.
Mailing Address:
City:
5.
Home Address / Permanent Address:
(if different from #4)
City:
6.
Period of Cover:
From:
(YYYY-MM-DD)
To:
(YYYY-MM-DD)
7.
INSURANCE COVER AVAILABLE:
Select cover required: (Tick the appropriate box)
A)
Comprehensive
Liability for Third Party Bodily Injury and Property Damage and loss of or damage
to the Insured's Motor Vehicle
B)
C)
Third Party Fire and Theft
Third Party
Liability for Third Party Bodily Injury and Property Damage and loss of or damage
to the Insured's Motor Vehicle by Fire or Theft
Liability for Third Party Bodily Injury and Property Damage
The following extensions are available at an additional cost. (COMPREHENSIVE COVER ONLY)
8. (a)
Do you wish to extend the policy to include windscreen damage?
Yes
No
Limit:
(b)
Do you wish to extend the policy to include a Partial Waiver of Excess? (Insured & Spouse Only)
Yes
No
(c)
Do you wish to extend the policy to include Consequential Loss?
Yes
No
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For Vehicles Valued
Policy Limit Per Day
Policy Limit for the Policy Period
Under $75,000.00
$250.00
$3,750.00
Yes
No
$75,001.00 to $150,000.00
$450.00
$6,750.00
Yes
No
Over $150,000
$650.00
$9,750.00
Yes
No
Where any benefit under these extensions is utilized during the period of insurance, refer to policy for options to reinstate.
(d)
Do you wish to extend the policy to provide New for Old replacement parts in the event of partial
loss or damage? (Restricted to vehicles under 5 years old from date of manufacture)
Yes
No
(e)
Do you wish to extend the policy to include the loss damage and / or liability arising from flood
hurricane windstorm tornado earthquake volcanic eruption or any other convulsion of nature?
Yes
No
9. Mortgagee Name (in full):
Mortgagee's Address:
City:
Name of Premium Financier:
Financier's Address:
City:
10. Particulars of vehicles to be insured 1 2 3
Make
Year of Manufacture
LOCAL DEALERSHIP
Yes
No
Yes
No
Yes
No
"Roll on-Roll off"
Yes
No
Yes
No
Yes
No
Type of Body and Transmission
Seating Capacity (Including Driver)
Horse Power or Cubic Capacity
Registered Letters and Number
Chassis Number
Engine Number
Date of Purchase and Price Paid
Estimated Present Value including
Accessories
If a GOODS VEHICLE, please state:-
(a) Maximum Carrying Capacity
(b) Value & carrying capacity of any
trailers
Is your Motor Vehicle fitted with an
anti theft device
Yes No
If yes please state name and type of
such device
NOTE: You are required to ensure that the Sum Insured is revised each year to reflect the current market value. Claims will be settled on an indemnity basis.
For total losses you will be paid the assessed pre-accident Value provided the Sum Insured is adequate
11.
If accessories are included in insured value, please state below:
Registration No. Item
Quantity Make Serial No.
Value
12.
Is your vehicle fitted with an anti-theft device?
Yes
No
If 'YES' please state the Vehicle Registration Number, name and type of such device:
13.
Is the vehicle kept in a locked garage?
Yes
No
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(13) If 'NO', please give particulars
Is the vehicle kept in an open car port within a fenced and locked area?
Yes
No
If 'NO', Please give particulars
14.
Is the Proposer entitled to a No Claim Discount from previous insurers in respect of any of the cars included?
Yes
No
Is the Proposer now insured or was formerly insured in respect of any vehicles?
Yes
No
If 'YES' state the name of Insurance Company:
Address of Insurance Company:
City:
15.
Do you have any other insurances with COLFIRE?
Yes
No
If 'YES' please give particulars:
16.
Has any Company or Underwriter at any time:
(a)
Declined a Motor Proposal from the Proposer?
Yes
No
(b)
Required an increased premium or imposed special conditions?
Yes
No
(c)
Cancelled or refused to renew an existing Motor Policy held by the Proposer?
Yes
No
If so, which Company?:
17.
NOTE: THE POLICY DOES NOT COVER DRIVERS WHO ARE UNDER THE AGE OF 25 YEARS OR WHO HAVE BEEN DRIVING FOR LESS THAN
TWO (2) YEARS, UNLESS SPECIFIED IN THE POLICY SCHEDULE.
Will anyone driving your motor vehicle
(a)
be less than 25 years of age ?
Yes
No
(b)
have less than 2 years driving experience?
Yes
No
If YES please give particulars of drivers under the age of 25 or who have been driving less than two (2) years
Name
Date of Birth
(yyyy/mm/dd)
Sex
(M/F)
Driver's Permit No:
Date of Issue and Class
Occupation
Relationship to Insured
18.
Particulars of drivers over the age of 25 or who have been driving more than two (2) years and who will drive the vehicle regularly:
Name
Date of Birth
(yyyy/mm/dd)
Sex
(M/F)
Driver's Permit No:
Date of Issue and Class
Occupation
Relationship to Insured
19.
In respect of this vehicle or any other driven by you or any of the proposed drivers has any loss, damage or liability arisen (including windscreen damage),
whether insured or not in the past three years? Give particulars of any Accidents or Losses (whether resulting in an insurance claim or not) during the last three years:
Year No. of Vehicles No. of Accidents and Losses Brief details of Accidents or Losses
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20.
Has the Proposer or any person who to the Proposer's knowledge will drive:
(a)
suffered from defective vision or hearing or from any disease or physical infirmity / disability?
Yes
No
(b)
been prosecuted for any traffic offences in the past four years?
Yes
No
(c)
been refused insurance or special conditions imposed or previous insurances terminated?
Yes
No
If YES, enter particulars:
21.
Is / are the car(s)
(a)
owned by the Proposer?
Yes
No
(b)
registered in the Proposer's name?
Yes
No
(c)
Modified or converted from maker's standard specifications
or is intended to be so
Yes
No
If YES, enter particulars:
22.
Please tick if the vehicle is to be used as follows:
(a)
Carriage of own goods only
(b)
General Cartage
(c)
Carriage of passengers -not for hire or reward
(Enter nature of goods)
(Enter number of passengers)
(d)
Carriage of passengers for hire or reward
(e)
Motor Trade
(Enter number of passengers)
(g)
Hauling more than one trailer
(f)
Social, domestic or pleasure purposes
N.B: The Limitations as to Use as stated on the Policy will be indicated by You above.
The source of funds for this transaction is:
As per requirements of the Proceeds of Crimes Act (Chapter 11:27) and Guidelines of Central Bank of Trinidad and Tobago, COLFIRE is required to verify the
source of funds before accepting premiums.
Consent is hereby given to COLFIRE to disclose information provided herein to Regulatory and Law Enforcement Authorities if required.
IMPORTANT NOTE: The questions on this Proposal generally supply sufficient information for us to assess the risk. However, there may be some special feature
concerning you or your vehicle, its location or use that is not covered by the questions but which might nevertheless affect our judgement. If you can think of anything
which might influence the likelihood or severity of a loss, please give full details below. If you are in any doubt whether a fact may affect our judgement you should
tell us as failure to do so may invalidate the Insurance.
DECLARATION:
I/We declare that I have read this document and to the best of my/our knowledge and belief, the above statements made by me/us or on my/our behalf are true and
complete. I/We agree that this Proposal and Declaration shall be the basis of the contract between me/us and Colonial Fire & General Insurance Company Limited
and I/We further agree to accept indemnity subject to the terms and conditions in and endorsed on the Company's Policy. I/We undertake that the motor vehicle to
be insured shall not be driven by any person who to my/our knowledge has been refused any motor vehicle insurance or continuance thereof.
Proposer's Signature:
Proposer's Signature:
Date:
Date:
(YYYY-MM-DD)
(YYYY-MM-DD)
Name of Company:
Authorized Signature:
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Designation:
Date:
(YYYY-MM-DD)
Intermediary Name:
Date:
(YYYY-MM-DD)
FOR OFFICIAL USE ONLY
File No.
Policy No.
Policy Type
Producer
Certified Copy of Ownership
received
Copy of Drivers Permit
Underwriter
Branch
Proof of SDD Discount
Download the form and fill it out on your computer.
When you are finished, save the form and submit via email to info@colfire.com
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