Private Motor Proposal PRIVATE MOTOR PROPOSAL FORM Step 1 of 4 25% 1) DETAILS OF THE PROPOSERNameFirstLastIdentity No Date of Birth Business or Occupation:AddressStreet AddressCityZIP / Postal CodePeriod of Insurance: From Period of Insurance: To 2) DETAILS OF THE DRIVER(a) Are you fully licensed for this class of vehicle? (b) Date when licensed Licence No:(c) If not licensed who will be driving the vehicle? (d) Details of relationship and licence details(e) Do you or any person who to your knowledge will drive your car suffer from any physical disability or infirmity? YesNoGive details (f) Have you or any person who to your knowledge will drive your car ever been convicted of any motoring offence?YesNoGive details (g) Have you ever been insured before? State company and type of cover Have you been refused insurance or had your policy cancelled or had special terms imposed on your policy before? DETAILS OF THE ACCIDENTS/LOSSES/CLAIMS DETAILS OF THE VEHICLE(a) Any radio/tape including type, serial numbers and value(b) Any special accessories including Models/Serial No.Please enter the product and the dollars Has the car been specially adapted/modified to increase performance? Is the vehicle registered in your name? Any hire purchase agreement?(e) Are there any visible markings known to you only? If so give details (f) Where is the vehicle normally garaged at night? (g) Give full details of any anti /hijack devices on vehicle and premises where normally garaged? (h) Will the vehicle be used for (use tick)- Carriage of fare paying passengers?YesNo- Carrying of explosives or inflammables?YesNo- Racing, rallying, driving schools?YesNo- In connection with Motor trade?YesNo- Social, domestic, pleasure purpose including use by YesNoyou for driving to and from your permanent work place? YesNo-As a taxi YesNoJ) Where is the vehicle normally used?(k) Do you wish to carry a voluntary excess? If so how much? (l) Do you wish to be covered against riot, strike and civil commotion? Type of cover required (please tick)ComprehensiveFull Third Fire and TheftFull Third PartyDo you require Inflation Provision percentage of the value stated below?