MOTOR FLEET. Proposal Form November 2004 Edition

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1 MOTOR FLEET Proposal Form vember 2004 Edition

2 Important tice To apply for the Motor Fleet Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue or black ink). You must complete all parts of this Proposal Form in all cases. Insurance begins when AXA Insurance has accepted your application. You must give full and true answers to all questions. If you do not do so your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied to AXA Insurance (including copies of correspondence). If the space provided is inadequate please supply full details using the Additional Information Section. A copy of this Proposal can be supplied on request, within a period of 3 months after its completion. A copy of the Policy is available on request. AXA Insurance UK plc is authorised and regulated by the Financial Services Authority. Law Applicable to Contract You are free to choose the law applicable to this Policy. Your Policy will be governed by the law of England and Wales unless you and we have agreed otherwise. Definition You/Your the Proposer Your Vehicle(s) vehicles owned by the Proposer or hired to them under a hire purchase or contract hire agreement or leased to them under a lease agreement. Private Type Vehicle this will be stated on the vehicle registration document Commercial Type Vehicle this will be stated on the vehicle registration document PART A SECTION 1 Cover Requirements See Product Guide for details of the cover available 1 Effective Start Date of Cover (DD/MM/YYYY) 2 Expiry Date (if less than 12 months) (DD/MM/YYYY) 3 Type of cover required: Comprehensive Third Party, Fire and Theft Third Party only 2

3 SECTION 2 Proposers Details Person or Company in whose name this insurance is required 1 Name (in full) 2 Postal Address Postcode (must be supplied) 3 Telephone Number 4 Address 5 Area where vehicles usually kept at night e.g. name of town, city and county or (if applicable) countrywide 6 Do you wish to pay by instalments? If '' please complete a Budget Plan Application SECTION 3 Proposers Business or Trade SECTION 4 Your Vehicle(s) You must include all vehicles that You wish to insure under this contract at the proposed effective start date of this insurance. If Your Vehicle is a Private Type Vehicle please state the engine size; if it is a Commercial Type Vehicle please state the Gross Vehicle Weight. Please note that the value of the vehicle should reflect it's current value, however this is not an agreed value contract and in the event of a total loss the market value of the vehicle will be assessed taking into consideration it's age and condition. Make and Model Engine size, or Gross Vehicle Weight Year of Make Value Registration Mark If there is insufficient space please provide a separate sheet. 3

4 SECTION 5 Use 1 Will any of Your Vehicles: a) be used within any secure areas where access is controlled by an airport or aerodrome authority, which are areas that are considered to be airside? b) carry Hazardous goods requiring special labelling as required by legislation, i.e. goods of an explosive, inflammable or toxic nature? c) or trailers carry stone, sand, gravel or ballast? d) carry passengers for financial reward e) carry goods which are not Your own property? f) carry goods beyond a 100 mile radius of the garage address of that vehicle? g) be used as working machinery, known as a tool of trade, i.e. JCB, if so do You require the working risks to be covered against i) Third Party Only ii) Accidental Damage to Your Vehicle and Third Party Additional Information: If the answer to Question 5 a) is please provide full details of the use If the answer to Question 5 e) is do you have an Operators licence? 4

5 SECTION 6 Drivers 1 Has any person to Your knowledge who may drive under this insurance: a) been diagnosed with a medical condition that is notifiable to the DVLA such as defective vision or hearing, heart condition, epilepsy, diabetes or any other physical mental disability or infirmity? b) been convicted during the past 5 years of any of the following offences: Manslaughter, reckless driving, causing death by reckless driving, driving under the influence of alcohol or drugs or any offence or combination of offences which resulted in suspension from driving? c) had insurance declined withdrawn or subjected to an increase rate or special condition? If any of the replies to the above section are give details below. Question. Name Details Date Cost/fine 5

6 Part B - Additional Information You should disclose all material facts as failure to do so could invalidate the policy. A material fact is information which is likely to influence an insurer in the assessment and acceptance of a risk. You must disclose all material facts about yourself, any other drivers, the vehicles and it's use that is known to you at the time of applying for this insurance. If you have any doubt as to whether a fact is material or not then please disclose it now in the following box to avoid any chance of invalidating the policy or prejudicing a claim payment. 6

7 Part C Declaration If you have not given full and true answers to all questions asked on this Proposal, your insurance may not protect you in the event of a claim. If you wish to disclose something that has not been disclosed elsewhere in this Proposal, please use the box provided here. Before signing the Declaration, please read the notices on this page about the Claims and Underwriting Exchange Register and Data Protection tice. Claims and Underwriting Exchange Register Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Database Services Ltd (IDS Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. When you tell us about an incident we will pass information relating to it, to the register. Your policy details will be added to the Motor Insurance Database (MID), run by the Motor Insurers Information Centre (MIIC). This may be consulted by: a) the Police for the purposes of establishing whether a driver's use of the vehicle is likely to be covered by a motor insurance policy and/or for preventing and detecting crime b) other UK insurers, the Motor Insurers' Bureau and MIIC may search the MID to ascertain relevant policy information if you have been involved in an accident in the UK or abroad c) the DVLA and DVLNI for the purposes of Electronic Vehicle Licensing d) persons pursuing a claim in respect of a motor traffic accident (including citizens of other countries) may also obtain relevant information which is held on the MID You should show this notice to anyone insured to drive the vehicle(s) under this policy. You can find out more about the Motor Insurance Database and it's use by contacting AXA or at Data Protection tice AXA Insurance UK plc is a member of the AXA Group. To set up and administer your policy we will hold and use information including sensitive personal information (sensitive personal information may include such things as criminal convictions and health information) about you supplied by you. We may send it in confidence for processing to other companies in the AXA Group (or companies acting on our instructions) including those located outside the European Economic Area. By signing this form you consent to such use of your personal data including sensitive personal data. AXA Insurance UK plc may send you details of our other products and services. To enable them to send you details of their products and services, we may also share your name and address with: other AXA companies within the European Economic Area other carefully selected companies outside the AXA Group. You may be contacted in writing or by telephone or fax. If you do not wish to receive such details please tick the appropriate box(es). Declaration Please read the Declaration carefully and then sign below. We declare that the answers given to questions asked in this Proposal are true and complete to the best of our knowledge and belief. We declare that all material facts, which is information that may influence the Company in the acceptance of this insurance and the terms provided, have been disclosed and recorded. We undertake that the motor vehicles to be insured will not be driven by any person who to our knowledge has been refused motor insurance or continuance thereof. We agree that this proposal and declaration shall be the basis of the contract between ourselves and AXA Insurance UK plc. Signature of Proposer, Partner or Company Director Date (DD/MM/YYYY) This Proposal Form must be submitted to the Company within 7 days of inception. Failure to do so will result in cover being effective only from the date it is received and accepted by the Company. Incorrect or misleading information, such as inappropriate business description or trade type, or incorrect completion of the Proposal Form will render the cover ineffective. cover is in force until the Proposal has been accepted by AXA Insurance UK plc. 7

8 AXA is a world leader in wealth management and financial protection. We operate in over 50 countries and serve more than 50 million customers worldwide. We cater to a wide range of needs, providing advice and guidance to our individual and corporate customers on a variety of financial products and services. In addition to Business, Motor and Home Insurance we also offer Investments, Life Assurance, Retirement Planning, Long Term Care, Asset Management, Medical Insurance and Dental Payment Plans. With our expertise and commitment to customer service and consistent, quality care, you can rely on AXA for lasting security. ASK ABOUT AXA S EXCELLENT RANGE OF BUSINESS, HOME AND MOTOR INSURANCE PRODUCTS MO006R/X (01/06) (10514) AXA Insurance UK plc Registered in England Registered Office 5 Old Broad Street, London EC2N 1AD. A member of the AXA Group of Companies. AXA Insurance UK plc is authorised and regulated by the Financial Services Authority. In order to maintain a quality of service, telephone calls may be monitored or recorded.

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