Farm Motor Proposal - Information andMotor Vehicle Insurance

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1 Farm Motor Proposal

2 MOTOR PROPOSAL Please read the following important notes before completing this proposal WARNING If you are in any doubt about a particular fact(s) being material to this insurance you should disclose it/them. Failure to disclose all material information may result in this insurance being void from inception leaving you without insurance cover. You should keep a complete record (including copies of all letters) of all information supplied to the Insurers for the purpose of entering into this contract of insurance. No cover is in force until a cover note is issued and the premium paid. 1. Proposer s full name and/or name of firm, including full names of trading partners (if applicable). 2. Address. Postcode 3. Daytime telephone number, including STD code. 4. Mobile telephone number. 5. Occupation (Full & Part-time). 6. Please state type of farming business undertaken (if applicable), i.e. arable, sheep, etc. 7. Please insert period of cover required, mths commencement date required and renewal date. 8. Do you own any motor vehicles other than those declared? 9. Have you ever traded under any other name? 10. Has any vehicle been modified from the manufacturers standard specification? (This includes cosmetic changes, e.g. body kits, alloy wheels, spoilers, side skirts, audio equipment etc.) 11. Are any of the vehicles kept at any address other than the address shown above? 12. Are any of the vehicles not registered in your name? 13. Do you wish to restrict the driving of any vehicle (not AV s)(a discount may be available)? 14. Will any driver under the age of 25 be the main user of any of the vehicles? If the answer to any of the above questions is, please provide details in the box below 15. Please give your details and those of all other persons who may drive the vehicles. Full Name Dateof Birth Occupation (Full/Part-time) Type of Licence Full UK, EC, etc. Date UK Test Passed Main user of which vehicle

3 A) PRIVATE CARS VEHICLES TO BE INSURED Make & Model Year of Manufacture Date of Purchase Cubic Capacity Estimated Value Registration Number Cover No. of Seats Voluntary Excess Bonus Years/ Protected B) GOODS CARRYING VEHICLES AND TRAILERS Make & Model Year of Manufacture Date of Purchase Gross Vehicle Weight Estimated Value Registration Number Cover No. of Seats Voluntary Excess Bonus Years C) AGRICULTURAL VEHICLES, INCLUDING TRACTORS, COMBINES & TRAILED IMPLEMENTS Make and Model including Type of Vehicle Year of Manufacture Date of Purchase Estimated Value Registration Number/Serial Number Cover Required Voluntary Excess Bonus Years Is this vehicle road registered?

4 16. USE a. Will any vehicle be used for any purpose other than social, domestic, pleasure or farm/estate use? b. Will any goods carrying vehicle be used for: (i) Journeys in excess of a 100 mile radius of base? (ii) Carriage of goods for hire and/or reward? c. Will any agricultural vehicles be used for: (i) Tree felling or haulage? (ii) Agricultural contracting? Please state the percentage (%) amount of contracting in relation to total farm income. d. Do you carry hazardous or dangerous goods? (e.g. corrosive, toxic, poisonous, radioactive, infectious, explosive, or inflammable goods) e. Do you visit hazardous or dangerous sites or locations? (e.g. chemical, oil, gas works or refineries, Nuclear installations, Power stations, Bulk storage or production premises in the Explosive, Ammunition or Pyrotechnic industries, Ministry of Defence premises, Military Bases, Airports/Airside or in proximity to aircraft, etc.) If you have answered to any part of question 16 please provide details in the box below 17. Have you or any person who may drive, including those declared under Question 15: a. Been refused motor insurance or had a motor policy cancelled, or had special terms imposed? b. Suffered from diabetes, epilepsy, heart conditions, defective vision or hearing, loss of limb or any other physical, mental or substance abuse condition? If you have answered to a or b of question 17 please provide details in the box below Name Details Onset Date Have DVLA been advised? c. Within the last five years been convicted of any motoring offence, or have any prosecutions pending? d. Been disqualified from driving or had a licence suspended or revoked within the last 10 years? If you have answered to c or d of question 17 please provide details in the box below Name Date Offence Code Period Disqualified Circumstances (including fine/penalty points

5 e. Had any accidents, claims or losses during the last three years, whether to blame or not? If you have answered to e of question 17 please provide details in the box below Name Date Circumstances Total Costs, AD, Vehicles Involved TP & PI 18. State name of previous/present insurers and policy number, and attach renewal notice/or if previously insured on a fleet basis, please attach claims experience (photocopies are T acceptable). INSURER POLICY. DECLARATION & IMPORTANT TES PERSONAL DATA The insurers for policies underwritten under this scheme are Norwich Union and Royal & SunAlliance. It is administered on their behalf by Towergate Underwriting Group Limited. To set up and administer your policy, Norwich Union, Royal & SunAlliance and Towergate Underwriting Group Limited will hold and use information about you supplied by you. They may send it in confidence for processing to other companies or those acting on their instructions including those located outside the European Economic Area. Towergate Underwriting Group Limited may also send you details of their other products and services. Please tick this box if you do not wish to receive such details. CUE/MIIC Insurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Ltd (IDS Ltd). The aim is to help us to check information provided and also to prevent fraudulent claims. When we deal with your request for insurance, we may search the register. When you tell us about an incident (such as a fire, water damage or theft) which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask us for more information about this. Your insurance cover details will be added to the Motor Insurance Database, run by the Motor Insurers Information Centre (MIIC). This has been set up to help identify uninsured drivers, and may be searched by the Police to help confirm who is insured to drive. If there is an accident, the Database may be used by insurers, MIIC and the Motor Insurers Bureau to identify relevant policy information. MATERIAL FACTS To the best of my/our knowledge and belief, the information provided in connection with this application, whether in my own hand or not, is true and I/we have not withheld any material facts. I/we understand that non-disclosure or misrepresentation of a material fact will entitle the insurer to void this insurance. (Note: a material fact is one likely to influence acceptance or assessment of this application by insurers). If you are in any doubt as to what constitutes a material fact, you should consult our office. IPT (INSURANCE PREMIUM TAX) The Finance Act 1994 requires us to levy Insurance Premium Tax at the prevailing rate on insurance business. For further information, please ask your broker or AIUA. Notes 1. We reserve the right to ask for special terms or decline the proposal. If we decline the proposal a premium will be payable by you for the period of cover stated in the official cover note. 2. A copy of this proposal will be supplied by us on request within three months of completion. 3. You should show this notice to anyone insured to drive the vehicle(s) covered under the policy. 4. In assessing your application and subsequent renewals we may search the files of licenced credit reference agencies. They may keep a record of the search on their files, and we may pass to to licenced credit reference agencies details of your payment record with us. Credit agency data is used by business to assess applications for insurance, banking loans, hire facilities and debt collection purposes. Proposer s Signature Date

6 Also available through Towergate Partnership Aviation Caravans & Caravan Parks Care Homes Classic Car Commercial and Mini Fleet Commercial Property Owners Commercial Vehicles Contractors Credit Dental Profession Directors & Officers Engineering Entertainment Industry Holiday Home and Expat Household Liability Licensed Trade Manufacturing Marine Craft Marine Trade Medical Profession Mini Bus Office Park Home Personal Accident & Sickness Photographic Industry Private Motor Professional Indemnity Residential Property Owners Retail Trade Sports & Leisure Travel Industry Veterinary Profession Wholesaling Please contact your Insurance Broker for further information Towergate AIUA 8 Grove Park Court, Harrogate, North Yorkshire, HG1 4DP tel: fax: Towergate AIUA & Towergate Underwriting are a trading name of Towergate Underwriting Group Limited Registered Address: Towergate House, Eclipse Park, Sittingbourne Road, Maidstone, Kent ME14 3EN Registered in England No Authorised and regulated by the Financial Services Authority 063/PF/02/09/0692/44470

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