PRIVATE CAR INSURANCE PROPOSAL FORM

Unless all material facts are disclosed, this insurance could be invalidated. Material Facts are those facts an Insurer would regard as likely to influence the acceptance and/or assessment of the Proposal. If you are in any doubt about whether facts are material, you should disclose them. A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract. A specimen Policy is available on request.

DATE INSURANCE IS TO BEGIN
(which cannot be before the proposal is accepted by the Insurers)

EXPIRY DATE

Name of Proposer:

NIB#:

Postal Address:

E-mail:

Occupation:

Employer:

Nationality:

Telephone:

Home:

Work:

Mobile:

Address at which car is normally kept:

House

Owned

Apartment

Rented

YOUR CAR(S)

Serial or Chassis Number

Year

Make

Model

Type of Body

Engine Capacity

Seating Capacity

Date of Purchase

Price paid by you

Insured's Estimate of Present Value

Serial or Chassis Number

Year

Make

Model

Type of Body

Engine Capacity

Seating Capacity

Date of Purchase

Price paid by you

Insured's Estimate of Present Value

Has your vehicle been modified in any way from the manufacturers' specification?

Yes

If 'Yes' Please give details below:

Do you own the vehicle? (For the purpose of this question buying the car under a bank loan signifies ownership.)

Yes

If 'No' Please give details below:

If a motor cycle, will it be used with a sidecar attached?

Yes

If 'Yes' Please give details below:

Does a bank or finance company have an interest in the vehicle?

Yes

If 'Yes' Please give details below:

DRIVERS

Driving will be restricted to persons named in your Policy.

Please note that copies of both sides of the driver's license for ALL drivers are required.

Give details of yourself and all others

Full Name

Occupation

Relationship to the Proposer

Date of Birth Day - Month - Year

Type of License

How long held

Likely % of use

Add Driver

Delete Driver

* A medical certificate is required for any driver who is seventy years of age or older.

Have you, or any of the persons who will drive:

Resided outside The Bahamas during the past 3 years?

Yes

If 'Yes' Please give details below:

Suffered from diabetes, epilepsy, heart condition or any other physical or mental disability, infirmity or disease?

Yes

If 'Yes' Please give details below:

Ever had any motor insurance declined, cancelled, renewal not invited or had special terms imposed?

Yes

If 'Yes' Please give details below:

Have you, or any of the persons who will drive:

Been convicted during the past 5 years of an offence in connection with a motor vehicle, or are any prosecutions pending?

Yes

If 'Yes' Please give details below:

Had a driving license suspended at any time?

Yes

If 'Yes' Please give details below:

Held a full driving license for less than 4 years?

Yes

If 'Yes' Please give details below:

During the past 4 years had any accident, loss or claim in connection with any motor vehicle?

Yes

If 'Yes' Please give details below:

Do you now hold, or have you during the past 2 years held a motor insurance policy in your own name?

Yes

if 'Yes' state: Present or Past Insurer and Policy Number:

If entitled to a No Claims Discount/Bonus from previous Insurers state number of years entitlement (and attach renewal notice or other confirmation of entitlement).

YOUR INSURANCE REQUIREMENTS

10. Tick type of cover required:

Comprehensive

Third Party Only

11.

Tick purposes for which vehicle will be used:

Social,domestic and pleasure

*Business

*If used for Business purposes, completion of a supplementary form will be required.

Racing, competitions, trials, or rallies, or the carriage of passengers for hire or reward are excluded in all cases.

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT 2003

The information supplied when arranging this insurance policy may be shared for insurance purposes and services with other companies and organisations. For full details please refer to the Data Protection Act Statement available from Insurance Management (Bahamas) Ltd.

DECLARATION

I/We declare that the above statements made by me/us or written in answer to the questions on this form on my/our behalf by someone else are to the best of my/our knowledge and belief true and complete, and no material fact has been misrepresented, misstated or withheld. I/We agree that this proposal shall form the basis of the contract between me/us and the Insurers and will be deemed as incorporated in the Policy to be issued.

II/We understand that in respect of comprehensive cover, in the event of the total loss of the motor vehicle, the Insurers liability shall be limited to the reasonable market value of the motor vehicle at the time of the loss but not exceeding the Insured's Estimate of Value as stated overleaf.

I/We agree that an electronically transmitted signature affixed to this document shall have the force and effect of an original signature.

PRIVATE CAR INSURANCE PROPOSAL FORM

YOUR CAR(S)

DRIVERS

YOUR INSURANCE REQUIREMENTS

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT 2003

DECLARATION

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