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1 fleetshield proposal form FOR OFFICE USE ONLY: Policy.: Authorised: Agency: Broker/Agent: Quote Ref.: premium: A full policy wording is available on request Important: It is an offence under the ROAD TRAFFIC ACT to make a false statement or withhold any material information for the purpose of obtaining a Certificate of Motor Insurance. Please ensure that this Proposal Form is completed correctly in every particular. Please complete in capital letters using an ink pen. proposer Name in Full Postal Address Postcode Telephone Number Full Description of Business If you own subsidiary companies are they all to be included? If only specified subsidiary or any associated companies are to be included please state names Insurance required from to 1

2 vehicles, trailers and cover te: The details of all vehicles and trailers to be insured at the inception of this insurance and the cover required are to be provided in the Vehicle and Trailer Particulars Section or in a similar format. 1. Please state total number of vehicles owned, hired, leased or lent to you 2. Do you require cover for trailers? If YES, (a) please state total number of trailers owned, hired, leased or lent to you (b) is cover required for unspecified trailers? 3. Where Comprehensive cover is selected do you wish to bear an excess in addition to the young and inexperienced drivers excess? If YES, please state the additional you wish to bear (if you require differing excess levels please detail your requirements in the Vehicle and Trailer Particulars Section or the Additional Information Section) 4. Do you ever have vehicles and/or trailers situated on the same premises where their total market value exceeds 250,000? If YES, please give full details below including total market value. DRIVERS 1. Is it your practice to examine the driving licence and make enquiries about the driving history of each person before they are first permitted to drive for you? 2. Have you or any person who to your knowledge will drive a vehicle: (a) in the past 5 years been convicted of any offences or have a prosecution pending relating to the following: (i) Dangerous Driving Drink/Drugs Taking/Stealing Failing to report an accident Driving without insurance (ii) Offences concerning the condition of vehicles exceeding permitted hours of driving? (c) been convicted of any offences involving dishonesty of any kind e.g. fraud, theft, arson or handling of stolen goods? (d) at any time been refused insurance or quoted an increased premium or had special terms imposed? (e) suffered from heart disorder, diabetes, fits or other mental or physical infirmity or, are you/they regularly taking any prescribed medication? (i) If YES, has the health condition been notified to the Driver Vehicle Licensing Agency (DVLA)? (ii) If the health condition has been notified to the DVLA, have they issued the driver with a licence? n.b. While some health conditions are acceptable to us, this in on condition that the DVLA have been notified where required and have issued a licence having assessed the person s fitness to drive. Advice should be sought from a GP if any driver is in any doubt as to whether a health complaint needs to be notified to the DVLA. If you have answered YES, to any part of Question 2, or NO to Parts (e) i) and/or (e) ii), then please give details below, or in the Additional Information section clearly indicating the Question numbers, Drivers names, dates and cost of claims (where appropriate). 2

3 USE 1. use of your cars for the business of the Policyholder (including Commercial Travelling), and for social, domestic and pleasure purposes is covered as standard other than for the business purposes shown below. Please indicate if you require cover for: (a) Carriage of passengers for hire or reward (b) Use in connection with the Motor Trade 2. Where Goods Carrying Vehicles are to be insured are they used for: (a) Carriage of own goods? (b) Carriage of other persons goods? 3. Please state below the general nature of goods carried and detail any inflammable, toxic, corrosive, explosive or otherwise dangerous substances 4. Are vehicles used at airfields? 5. Are vehicles hired or leased to other persons? 6. Are vehicles used outside the United Kingdom? If you have answered YES, to Questions 4, 5 or 6, please give full details below or in the Additional Information section It will be a condition of the policy that you will supply vehicle details for the purpose of populating the Motor Insurance Database (MID). Our preferred method is via RSA s website. You will be provided with a Userid, Password and User Instructions for this purpose. This means that you or your authorised representative will require internet access. Please note that completion of this section does not fulfil the proposer s responsibility to supply details of those vehicles, whose use is covered by the policy, to the MID via the RSA website. vehicle and trailer particulars make model and body type registration identification number vehicle 1 capacity or g.v.w. year of make estimate present value garage district postcode policy 2 cover excess 3 3

4 Trade plate registration number policy cover 2 (road Risks Only) excess 3 1. VEHICLE CAPACITY OR G.V.W. Motor Cars & Motor Cycles Goods Carrying Vehicles under 3.5 tonnes gross vehicle weight All other Goods Carrying Vehicles Mini Buses & Motor Coaches Cubic Capacity Carrying Capacity Gross Vehicle Weight Number of Passenger Seats 2. POLICY COVER A Comprehensive B Third Party Fire & Theft C Third Party Only 3. EXCESS In addition to any young or inexperienced driver excess Claims Your existing Insurer will usually provide the claims experience in the form required below. 1. Please state name of your present Insurer 2. (a) Have you already provided us with details of previous claims experience for each of the last three years? (b) If YES, are these details still an accurate statement of your claims experience? (c) Do the details include the claims experience for all vehicles owned, hired, leased or lent to you? If the answer to any part of Question 2 is NO, please complete the following for the current and previous two periods of insurance. period total Number of vehicles owner, hired, leased or lent to you total Number of accidents and losses damage to proposer s vehicles settled claims third party claims not yet settled damage to proposer s vehicles third party Please state the date to which this experience is compiled additional information 4

5 important Please read the following carefully before you sign and date the Declaration as it contains important information relating to the details that you have given us. Law Applicable Unless the parties have agreed otherwise in writing any legal proceedings between them in connection with this contract will only take place in the courts of the part of the United Kingdom in which the policyholder is based, or, if the policyholder is based in either the Channel Islands or the Isle of Man, the courts of whichever of those two places in which the policyholder is based. Data Protection tice You should show this notice to any other party related to this insurance. We are required to send you this information to comply with current Data Protection legislation. It explains how we may use your details and tells you about the systems we have in place that allow us to detect and prevent fraudulent applications and claims. The savings that we make help us to keep premiums and products competitive. Data Protection Act 1998 All personal information supplied by you will be treated in confidence by the RSA Group of companies and will not be disclosed to any third parties except where your consent has been received or where permitted by law. In order to provide you with products and services this information will be held in the data systems of the RSA Group of companies or our agents or subcontractors The RSA Group of companies may pass your personal information to other companies for processing on its behalf. Some of these companies may be based outside Europe in countries that may not have laws to protect your personal information, but in all cases the Group will ensure that it is kept securely and only used for the purposes for which you provided it. Details of the companies and countries involved can be provided to you on request. Motor Insurance Database Your policy details will be added to the Motor Insurance Database (MID), run by the Motor Insurers Information Centre (MIIC). MID data may be used by the DVLA and DVLNI for the purpose of Electronic Vehicle Licensing and by 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. If you are involved in an accident (in the UK or abroad), other UK insurers, the Motor Insurers Bureau and MIIC may search the MID to obtain relevant policy information. Persons with a valid claim in respect of a road traffic accident (including citizens of other countries) may also obtain relevant information which is held on the MID. You can find out more about this from your insurer, or at Fraud Prevention, Detection & Claims History In order to prevent and detect fraud we may at any time: Share information about you with other organisations and public bodies including the Police; Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this. We and other organisations may also search these agencies and databases to: Help make decisions about the provision and administration of insurance, credit and related services for you and members of your household; Trace debtors or beneficiaries, recover debt, prevent fraud and to manage your accounts or insurance policies; Check your identity to prevent money laundering, unless you furnish us with other satisfactory proof of identity; Undertake credit searches and additional fraud searches. We can supply on request further details of the databases we access or contribute to (see below). Claims History 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. (NB is this necessary re above in blue). When we deal with a request for insurance, we may search these registers. 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 registers. We may search these databases when you apply for insurance, in the event of any incident or claim, or at time of renewal to validate your claims history or that of any other person or property likely to be involved in the policy or claim. 5

6 How to contact us On payment of a small fee you are entitled to receive a copy of the information we hold about you. If you have any questions, or you would like to find out more about this notice you can write to Data Protection Liaison Officer Tower Insurance Company Ltd PO Box 27 Jubilee Buildings 1 Victoria Street Douglas Isle of Man IM99 1BF important Please read the following carefully before you sign and date the Declaration as it contains important information relating to the details that you have given us. The questions on this form and any other details we specifically request, relate to facts considered material to underwriting the insurance. If you answer them fully and honestly you will be considered to have fulfilled your duty to disclose material facts. Failure to do so may invalidate your insurance. If in response to any of these questions you are in any doubt whether a fact is material you should disclose it. Please note that you are not required to disclose convictions regarded as spent by virtue of the Rehabilitation of Offenders Act You should also keep you own record (including copies of letters) of all information supplied to us in arranging this insurance. A copy of your completed Proposal is available on request. Please tick box if required The Insurers reserve the right to confirm driving licence details with DVLA. Declaration Before signing the Declaration please check your answers carefully particularly if this Proposal Form is not completed in your own hand. I/We declare that to the best of my/our knowledge and belief the answers given are true, the vehicle(s) is/are in a sound and roadworthy condition and all material information as explained has been disclosed. I/We agree that if any answers have been completed by any other person, such person shall for that purpose be regarded as my/our agent and acting on my/our behalf, and not the agent of Tower Insurance Company Ltd. I/We declare that the vehicle(s) to be insured shall not be driven by any person who to my/our knowledge has been refused insurance or renewal of insurance. I/We declare that this proposal is for insurance in the normal terms and conditions of the Insurer s policy and shall be incorporated in and form part of the insurance contract. I/We understand that you will pass the information on this form and about any incident I/we may give details of to IDS Ltd and ABI so that they can make it available to other insurers. I/We also understand that, in response to any searches you may make in connection with this application or any incident I/we have given details of, IDS Ltd and ABI may pass you information it has received from other insurers about other incidents anyone insured to drive the vehicle covered under the policy have been involved in. I/We understand that under the terms of the Motor Vehicles (Compulsory Insurance) (Information Centre & Compensation Body) Regulations 2003, I/We have a responsibility to maintain an up to date record of your UK registered vehicles on the Motor Insurance Database (MID). Signature of Proposer(s) and position in Company Date This insurance will not commence until the Insurers have indicated their acceptance of the Proposal and a Cover te or Certificate of Motor Insurance has been delivered. The Insurers reserve the right to decline any Proposal. Please initial any alterations on this Proposal Form. Tower Insurance Company Limited. Registered in the Isle of Man. 521 Registered Office Jubilee Buildings, 1 Victoria Street, Douglas, Isle of Man, IM99 1BF Authorised & Regulated by the Isle of Man Government Insurance & Pensions Authority. Member of the Isle of Man Financial Services Ombudsman Bureau. Tower Insurance Company Limited is a member of the RSA Group of companies. UKC December 2012

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