Untitled Document
Google
  Bancassurance Login
Username:
Untitled Document
Home » Commercial Insurance » Quotes and Forms » Forms
  PROPOSAL FOR MOTORCYCLE INSURANCE  
     
 

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

1.
(a)  Proposer
Agent Individual
  Surname *  
  First Name *  
  Other Names  
         
(b) Full Postal Address *
(to which all correspondence would be sent)		  
  Tel. No. *  
         
  Permanent Address  
  Tel. No.  
         
(c) Occupation
(Pls give full details)		  
  Fax. No.  
  E-mail Address *  
         
(d) Date of Birth
Day   Month  Year
 
         
(e) Nationality
(if not Nigerian)		  
         
(f) Marital Status
Married Single
 
         
2. (a) Are you the owner of the Motor Cycle?

if not state details of the owner
Yes No
 
Surname
First Name
Other Names
     
Contact Address
     
     
  (b)  Is the Motor Cycle registered in your name?

if not state details of the person in whose name Motor Cycle is registered
Yes No
 
Surname
First Name
Other Names
     
Contact Address
     
  (c) Did you obtain a loan to purchase the Motor Cycle?
Yes No
  if so, state name of sponsor
3.

Particulars of all Motor Cycles to be insured

Cycle 1 Cycle 2
a. Make of each Cycle *
b. Index mark & registration no. *
c. Cubic Capacity
d. Year of manufacture
e. Date of purchase
f. Whether new or secondhand at time of delivery
g. Proposer's estimate of present value (including side car (if any) and accessories thereon)
h. Engine No. *
I. Frame No. *
j. Will the Motor Cycle be used for the carriage of goods (other than samples) in connection with any trade or business?
k. Will the Motor Cycle be used only with a Side Car attached?
4. Do you or does any person who to your knowledge will ride, suffer from defective vision or hearing or from any physical infirmity or disability? if yes give details 
5. Have you or has any person who to your knowledge will ride,
(a) Ever had a licence for driving motor Cycles suspended? Yes No
(b) been convicted during the last five years of any offence in connection with any motor Cycle, or is any prosecution pending? Yes No
6.
How long have you held a driving license?
7. Are you now or have been insured in respect of any Motor Cycle or other Motor cycle? If so, state name and address of Company or Underwriter.
8. Has any Company or Underwriter ever:
(a) Declined your proposal Yes No  
(b) Required you to carry the first portion of any loss? Yes No  
(c) Required an increased premium or imposed special conditions? Yes No  
(d) Refused to renew policy? Yes No  
(e) Cancelled your policy? Yes No  
9.


CLAIMS HISTORY
Please give a summary of any losses sustained in the last year

TOTAL COST OF SETTLED CLAIMS

Damage to Own Cycle Third Party Others
Claim No.: Claim No.: Claim No.:
Amount: Amount: Amount:

Total number of Accidents and Losses

Year Number
Year Number
Year Number
Year Number

(No acknowledgement of any Premium or Deposit is valid unless upon the Company's Printed form)

CLAIMS NOT YET SETTLED

Damage to Own Cycle Third Party Others
Claim No.: Claim No.: Claim No.:
Amount: Amount: Amount:

Total number of Accidents and Losses

Year Number
Year Number
Year Number
Year Number

 
10. Are you entitled to a "No Claim Discount" from your previous insurers in respect of any of the Cycles described in this proposal? Check box if yes  
11. You wish to insure in respect of
(a) Comprehensive Benefits
(b) Third Party Liability, Fire & Theft of the Cycle
(c) Third Party Liability only
(d) Ordinance Liability only
I agree with all the terms and conditions. click here to read terms and conditions.

Follow this link to go back the page you were previously looking at.
Untitled Document
Copyright 2007 Leadway Assurance Company Limited. | Web Mail All rights reserved.