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Home » Commercial Insurance » Quotes and Forms » Forms
  PROPOSAL FOR PRIVATE MOTOR VEHICLE 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 car?

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

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

Particulars of all Vehicles to be insured

Vehicle 1 Vehicle 2 Vehicle 3
a. Make of each vehicle *
b. Index mark & registration no. *
c. Type of body
d. C.C.
e. Number of seats including driver
f. Year of manufacture
g. Date of purchase
h. Whether new or secondhand at time of delivery
i. Proposer's estimate of present value (including accessories thereon)
j.. Chasis No. and Engine No. *
k. Will the car be used solely for social, domestic and pleasure
Social
Domestic
Pleasure
Social
Domestic
Pleasure
Social
Domestic
Pleasure
l. other uses of car
m. Will the Car be driven EXCLUSIVELY by (i) Yourself  
  (ii) One or more other person? If so, State name in full of each such other persons and whether he / she is a paid driver.
n. If the Car will not be driven exclusively by you, state in respect of each other person who to your knowledge will drive  
  (i) His / Her Age  
  (ii) How long he/she has been driving motor vehicles continously?  
  (iii) Whether he/she has had any motor vehicle accidents or losses during the last three years  
         
4. Do, you or does any person who to your knowledge will drive, 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 drive,
(a) Ever had a licence for driving motor vehicles suspended? Yes No
(b) been convicted during the last five years of any offence in connection with any motor vehicle, or is any prosecution pending? Yes No
6.
(a) How long have you held a motor vehicle driving license continuously?
(b) Do you, or does any person who to your knowledge will drive, hold a provisional or learner's driving license? Yes No
(c) Will the motor Vehicle be driven by any person who to your knowledge has held for less than one year a full license to drive such vehicle? Yes No
7. State total number of Motor Vehicles owned by you during each of the last three years.  
Year No. of cars
8. Are you now or have been insured in respect of any Motor Vehicle? If so, state name and address of Company or Underwriter.
9. 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  
10.


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

TOTAL COST OF SETTLED CLAIMS

Damage to Own Vehicle 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 Vehicle 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

 
11. Are you entitled to a "No Claim Discount" from your previous insurers in respect of any of the vehicles described in this proposal? Check box if yes  
12. Do you wish to be covered under the following extensions:
(a) Strike Riot and Civil Commotion
(b) Third Party Property Damage extension
(c) Flood
13. You wish to insure in respect of
(a) Comprehensive Benefits
(b) Third Party Liability, Fire & Theft
(c) Third Party Liability only
I agree with all the terms and conditions. click here to read terms and conditions.

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