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Motor_KYP_Compliant_Proposal_Form

The document is a motor insurance proposal form that collects personal and vehicle information from the proposer. It includes sections for personal identification, vehicle details, coverage options, and usage information. The proposer must declare the accuracy of the information provided, which will form the basis of the insurance contract.

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didimoonlite
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26 views3 pages

Motor_KYP_Compliant_Proposal_Form

The document is a motor insurance proposal form that collects personal and vehicle information from the proposer. It includes sections for personal identification, vehicle details, coverage options, and usage information. The proposer must declare the accuracy of the information provided, which will form the basis of the insurance contract.

Uploaded by

didimoonlite
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MOTOR INSURANCE – Proposal Form

Important Notice: An Insurance agent who completes a Proposal Form for a Proposer is deemed to have
done so as the agent of the Proposer.

PROPOSER’S PERSONAL INFORMATION

1. Surname: Title:

2. Other Names:

DD MM YEAR
3. Gender: Date of Birth:

4. Means of Identification/Details (Please attached a photocopy while original copy will be sighted):

National ID Card ID Card/License/Passport No.

Drivers License Date of Issue: DD MM YEAR

International Passport: Expiry Date: DD MM YEAR

5. Tax Identification Number (TIN):

6. Occupation: Source of Income:

7. Bankers:

8. Business Address:

9. Residential Address:
(Please attach a copy of
current Utility Bill)

10. Telephone Nos.: (a) Home:

(b) GSM:

11. E-mail Address:

FOR OFFICE USE ONLY

12. Expected Premium:

13. Risk Category


14. Please state particulars of the Motor Vehicle /Cover Required
Name of Owner:

Registration Number: Chasis Number:

Engine Capacity: Engine Number:

Make of Car Year of Manufacture:

Colour: Number of Seat including


Driver.

Date of Purchase: Purchased brand new


or second hand?
Amount Purchased: Current Value of the car: N
N

15. Please state the full address of the current location of the motor vehicle where it can be inspected:

16. Select Type of Cover Required: (Please tick one only)


COMPREHENSIVE THIRD PARTY, FIRE & THEFT THIRD PARTY ONLY

OTHER COVER (Please describe): …………………………………………………………………

17. If you are not the sole owner, please state the name and address of the Finance, Hire Purchase
Company or any other interested party.

USAGE OF VEHICLE/GENERAL INFORMATION


18. For what purpose is the motor vehicle described above used?

19. Who drives/will be driving the car? (a) Self only: (b) Any licensed driver

20. Do you or any other person that will drive the motor vehicle suffer from any physical infirmity, vision
or hearing defect?

21. How many years have been driving?


22. Have you ever been convicted, fined or had your license withdrawn for driving offence?
23. Has any insurer ever declined your proposal, cancelled your Policy, refused renewal; increased your
Premium or imposed special conditions on your Motor Insurance?
24. Please give particulars of major accidents or losses during the past three years regarding motor vehicles
owned or used by you (whether insured or not)

Year No. of accidents Amout Spent on Repairs of Your Amout Spent on Repairs/
Own Vehicle (s) Settlement of Third parties

25. DECLARATION

I declare that the information provided above is true and correct to the best of my knowledge. I also
understand that the information provided shall form the basis of Insurance Contract between me and the
Company.

Signature Date

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