Motor Cycle proposal Form

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:: Motor Cycle Proposal Form & Questionaire


Branch : Head Office	Producer : Direct

Proposer: \|	Date of Birth:\|
Address: \|
Profession: \|	E-mail: \|
Telephone: \|	Office: \|
Period Of Cover: \|

Motor Cycle Make: \|	Model: \|	Year: \|
Chassis No.: \|	Cubic Capacity: \|
Engine No.: \|	H.P.: \|	Plate No.: \|

Cover : Third Party Liability US$50,000

Note:	1.	Cover is only available for Motor Cycle whilst being used for pleasure only.
	2.	Cover is only available for Harley-Davidson Motorcycles or similar "cruising style" Motor Cycles by other manufacturers.
	3.	Subject to the answers to this Proposal being satisfactory, the Premium will be US$75.00 for a twelve month period.
	4.	4. This Proposal Form, the Premium and all other documents should be delivered to Cumberland Insurance at the address shown below.

HAVE YOU HAD ANY ACCIDENTS IN THE LAST 5 YEARS, INSURED OR OTHERWISE? YES / NO. IF YES, PLEASE DETAIL THESE BELOW.

I, the undersigned;

1.	do declare all of the above information, whether completed by me/us in our own handwriting or not, to be true and acknowledge that this Proposal and Questionnaire will form the basis of my Contract of Insurance with Cumberland Insurance and Reinsurance Company s.a.l.;
2.	agree to maintain the Motor Cycle in accordance with the manufacturer's recommendations.

I attach a copy of the Motor Cycle's Registration Document and my Driving License.

I also agree to notify Cumberland Insurance and Reinsurance Company s.a.l. of any changes to the information detailed hereon.