Motor Vehicle proposal Form

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:: Motor Vehicle Proposal Form & Questionaire


Branch : \|	Producer : \|

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

Vehicle Make: \|	Model: \|	Year: \|
Chassis No.: \|
Engine No.: \|	H.P.: \|	Plate No.: \|
Vehicle use :\|

Cover Required:
(Please Tick The Box indicating Cover Required and Insert Monetary Amounts)

Third Party	: Limit of Idemnity -US$
Own Damage	: Value of Vehicle -US$
Fire	: Value of Vehicle -US$
Theft	: Value of Vehicle -US$
Personal Accident	: Driver	-Name:	\|
	: Passengers	-Number:	\|

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

I/We the undersigned 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/our Contract of Insurance with Cumberland Insurance and Reinsurance Company s.a.l. I/We also agree to notify Cumberland Insurance and Reinsurance Company s.a.l. of any changes to the information detailed hereon.

Signed by the Proposer

Dated

For Office USE only
Rate: tp	Comp	Fire	Theft
Excess:		IG	Dag
Rated	Approved		Date