Application form. Application for Motor Vehicle Insurance & PAI - BES. 1. General information. 1. Contracting party. 1.

Transcription

1 Application for Motor Vehicle Insurance & PAI - BES Broker: Policy number: Application form Check desired insurance: Please fill in completely and check where applicabl 1. General information Name and initials g. i. j. k. l. m. n. o. p. q. r. s. Address / district Address for collection Area and island Telephone number Date of birth Gender Identity number Profession / occupation (go directly to question 11 if application is only for PAI) Year of issue first license Category License number Date of issue / Renewal Physical defects or any diseases? If so, which? Previous motor vehicle insurances? If so, with If t, where were you previously insured? Did any company ever - refuse your application? If so, for what reason? - cancel your insurance? If so, for what reason? - set restrictive conditions? If so, for what reason? In how many accidents were you involved during the past 3 years? Have your even been criminally convicted? Has your license ever been suspended or revoked? Particulars Autoflex Simple Autoflex Autoflex 1. Contracting party Casco plus 1 Casco plus 2 Casco plus 3 g. male female g. male female i. j. k. Date: A / B / C / D / E l. m. m. n. o. p. q. r. s. 1. Regular Driver n. o. q. r. i. j. k. Date: A / B / C / D / E l. p. s. 2. Relationship contracting party/driver: Relationship contracting party with driver Who is the owner of the motor vehicle? 2. Name:

2 3. Date, premium and duration Inception date of the insurance Contract expiry date Payment of premium Duration of the insurance 3. Date: b ongoing half-yearly annually ending, date: quarterly in 2 terms 4. Information concerning other insurance Do you currently have insurance with Fatum? If so, which insurance and what are the policy numbers? 5. Description motor vehicle Brand: Type: Further: gasoline diesel Motornr.: Chassisnr.: Cylinder capacity: Load capacity: Manufacturer year: g. License plate: Number of seats: 4. motor liability medical fire/content life Accessoires Airco Tapeplayer Automatic Transmission Powerbrakes/steering Powerwindows Rust proofing* Other treatments* Extra accessories* *Do you want to include these in the insured value? Value: 6. Type of motor vehicle passenger car van station wagon pick-up jeep dumptruck truck trailer-truck bus/taxi motor-cycle moped Type hard top soft top convertible 7. Use of motor vehicle private purposes business purposes transportation of own merchandise transportation of merchandise for third parties with trailer distribution of newspapers, diary, bakery, beverages, laundry, flowers et rental taxi / bus number of passengers to be insured: any other purpose please describe: 8. Value of motor vehicle catalogue value Actual cash value Purchase price Date of purchase Financing-/hire purchase clause beneficiary 8. Date: new paid cash Name: Address: second-hand financing overyeared g. Leasing clause beneficiary Purchased from Name: Address: g. Name: Address:

3 9. Coverage Amount insured for liability: 50, , Deductible A compulsory deductible is applicable for every claim. Do you prefer a voluntary higher deductible? If so, for what amount? Note: Upon request deductible can be increase The minimum deductible will remain in effect deduction: 10% deduction: 17.5% deduction: 25% 11. Accident insurance for the occupants of the car Do you want an accident insurance for the occupants of the car? 11. Amounts to be insured (per car). : 1. A. Death: 11, , , ,000.- B. Permanent disablement Annual premium driver excluded Annual premium driver included 2. Inclusive of insurance against costs of medical treatment to a maximum of: Annual premium driver excluded Annual premium driver included Do you wish to have personal insurance or bound to a particular car? In case of insurance bound to a particular car, please give make of car, engine number and license plate number: 28, , , , , , , , personal car The undersigned declares that the above questions have been answered completely, accurately and truthfully, and that the motor vehicle is and will be kept in good condition. Date: Signature of the applicant/contracting party: Signature of the parent or guardian applicant: Space for remarks and/or premium calculation

4 See to it that you have an accident insurance for the occupants of your car. You do t have a car all to yoursel Often eugh, you will have relatives, friends and relations in your car. But then you need more than just seats for your passengers. For you are -with the steering wheel in your hands- the captain on the ship. And this creates quite some responsibility with regard to your fellow travelers. -often beloved- fellow passengers, don t you? Without an accident insurance for occupants of your car, such a gesture will be far beyond your financial capacity. So, seats alone are t eugh! Not for your passengers and t for you. Application form Your car insurance does t always cover the damage that your passengers could suffer due to an accident with your car. That insurance only covers the damage, if you are legally liable for suc If ather person is at fault, that person is then liabl But if that other person is t insured, your occupants will seldom be able to count on a reasonable compensation. And certainly t, if the damage is extensive! Besides, there are many situations conceivable in which it is t possible to point out a guilty party: a stone against the windshield, bad road surface, a blow-out, crossing sheep, goats and dogs. In all these cases, you are t liable according to the law. So compensation for the passengers who are under your car Well, there you are! Even though you may feel as incent as a new-born babe, you will still feel something like a moral obligation. And you want to bear part of the financial consequences of your The accident insurance for occupants of cars applies to all passengers who are transported free of charge and with the permission of the policyholder, irrespective of where the car itself is insure The insured sums per passenger (or, if the driver is co-insured, per occupant) are the sums insured per car, divided by the number of passengers insured at the time of the accident (alt. occupant). For persons who are 70 years of age and older, there is an annual interest payment for life equal to 5% of the capital in question, in stead of a capital benefit in the event of permanent disability. For persons who are 70 years of age and older or under 16 years of age, t more than will be paid per person at death, irrespective of the amount of the insured sum.

5 Ascertaining and verifying your identity Within the framework of national and international legislation and regulations, such as the prevention of money laundering and fi nancing of terrorism and the Offi ce for the Disclosure of Unusual Transactions, Guardian Group, and its affi liated companies such as Fatum Holding N.V., Fatum General Insurance N.V., Fatum General Insurance Aruba N.V., Fatum Health N.V., Fatum Life N.V. and Fatum Life Aruba N.V. (hereinafter referred to as: Guardian Group ), in its capacity of insurer (fi nancial service provider), is obliged to verify your identity. This enables us to establish whether the identity you have given us matches your true identity. The aforesaid means that Guardian Group will ask you, regardless of you being a private or business client, to identify yourself by means of valid ID/original documents, prior to providing you with a service or entering into a business relationship with you. Subsequently, Guardian Group will make clear (color) copies of your valid ID/original documents and arrange for you to sign and date these copies. These copies are deemed to form an integral part of your request and will be fi led in the dossier held by Guardian Group, together with this form. Any personal data will be stored by us in the Guardian Group client administration. The various regulators will ensure that Guardian Group, in its capacity of insurer and fi nancial service provider, will correctly and properly meet and fulfi ll its statutory obligations with regard to ascertaining and verifying your identity and, if (legally) required, the disclosure of personal data to third parties. The applicable diagram below is to be completed by a Guardian Group staff member or a Guardian Group intermediary. Valid IDs in the event of natural persons and/or executive legal persons* Policyholder Insured Premium contributor Beneficiary Number Rnwl date Number Rnwl date Number Rnwl date Number Rnwl date ID card (sédula) or Driver license or Passport (*) A copy of an (expired) ID card (sédula), driver license or passport is t accepted as valid ID. Original documents in the event of legal entities Policyholder Insured Premium contributor Beneficiary a) Extract from the Commercial Register of the Chamber of Commerce** and, among other things, b and c: b) Articles of Association and c) Shareholders register Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ (**) A copy of an extract for the Commercial Register of the Chamber of Commerce and/or older than six (6) months is t accepted as an original document. (Yes/) Delete as appropriat To be completed by a Guardian Group staff member or a Guardian Group intermediary: I (full surname and fi rst name of Guardian Group staff member or Guardian Group intermediary***), herewith declare that I have accepted the original and valid ID/original documents referred to by me in the above diagrams, and that I have made clear (color) copies from these, which copies are deemed to form an integral part of the client s request and which will be added by me to the Guardian Group dossier. Country : Date : Signature : (***) Delete as appropriat This translation has been issued for the convenience of our English speaking customers. The contract is exclusively governed by the Dutch wording of the policy.

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