Motor Trade Road Risks Proposal Form
PLEASE ANSWER ALL QUESTIONS FULLY IN BLOCK CAPITALS If there is insufficient space for any answers please continue on the back page 1. PROPOSER Mr Mrs Miss Ms Surname (or trading name) Forenames Marital status Home address Postcode Period of insurance Cover to commence : hours on / / for 12 months Work address Telephone Nos. (Home) Postcode Broker use only - FSA Client Classificationplease tick (Business) Retail ( ) Commercial ( ) Nationality birth Full time occupation Part time occupation Business e-mail address V.A.T registered Yes No 2. BUSINESS DETAILS Please describe your Business or Trade in percentage terms below:- (a) Vehicle purchase and re-sale (c) Mechanical and/or Servicing (e) Body repairs (g) Vehicle delivery and/or collection (i) Car breaking and/or sale of second hand parts (k) Body builders and/or commercial vehicle repair (l) Any other use please specify (b) Car accessories and fitting (d) Valeting (f) Renovations (h) Accident and/or breakdown recovery (j) Motorway recovery 3. VEHICLE TYPE - NOTE Cover may be restricted or terms applied for certain categories of Vehicle Please specify in percentage terms below:- (a) Private car (b) Commercial under 3.5 ton G.V.W (c) Motor cycle/scooters/quads or Trikes (d) Commercial over 3.5 ton G.V.W (e) Sports or high performance (f) Coaches/minibuses/vehicles with more then 6 seats (g) American/Canadian vehicles (h) Grey imports (i) Custom/kit built cars (j) Breakdown Trucks/Recovery/Vehicles with Trailers (k) Vintage/classic cars 2621/MTRR/PROPFORM/MAR14 P2/7
4. VEHICLES Please give full details of all vehicles NOTE: Vehicles owned by a spouse, common-law spouse, employees or additional drivers are not covered. Failure to declare ALL vehicles may invalidate your policy with the result that any claim will be rejected. Use a separate sheet if more space is needed. Make/Model Body Type Year of Make C.C/Plate or Gross Vehicle Weight Purchase Price Paid Estimated present Trade Value Full Registration No. Are any of the Vehicles listed under Question 4:- (a) Modified, Customised or altered in anyway Yes No (b) Left Hand Drive Yes No (c) Fitted with more than 7 seats including the Driver Yes No (d) Recovery Vehicle or Transporter Yes No capable of carrying in excess of 2 Vehicles If you have answered YES above, please give full details below or overleaf if required. 5. TRADE PLATES Do you have Trade Plates? Yes No If YES, Please give Trade Plate Numbers: 6. USE Besides Motor Trade use and Social Domestic and Pleasure, will any driver require other business use? If yes, advise driver and full details of use required. N.B. Requests for cover for other business use must be referred to QBE Insurance (Europe) Limited. Yes No 7. MOTOR INSURANCE DATABASE AS A RESULT OF THE 4TH EU MOTOR INSURANCE DIRECTIVE YOU ARE OBLIGED TO PROVIDE THE MOTOR INSURANCE DATABASE (MID) WITH THE REGISTRATION NUMBERS OF ALL VEHICLES THAT ARE OWNED BY YOU AND THAT WILL BE DRIVEN, USED OR PARKED ON A ROAD OR PUBLIC PLACE. QBE Insurance (Europe) Limited will inform the MID of the details of all Vehicles declared on the proposal form at inception. Thereafter it will be YOUR responsibility to notify the MID immediately you take possession of any Vehicle and/or when you dispose of any Vehicle. PLEASE INDICATE BELOW HOW YOU WISH TO ADVISE THE MID OF CHANGES. Tick here if you have access to the Internet and wish to apply for authorisation to directly notify the MID of all Vehicle changes. Procedures and Instructions will be issued by your intermediary. Tick here if you do not have access to the Internet and wish to notify your intermediary of all Vehicle changes who will then inform the MID on your behalf. FAILURE TO DISCLOSE INFORMATION TO THE MID MAY INVALIDATE YOUR POLICY WITH THE RESULT THAT ANY CLAIM WILL BE REJECTED. 2621/MTRR/PROPFORM/MAR14 P3/7
8. COVER REQUIRED Indicate (3) required Comprehensive Third Party Fire & Theft Third Party Only OWN VEHICLE INDEMNITY Third Party Fire & Theft max 7500 Please tick (3) Indemnity Limit required 2,500 5,000 7,500 10,000 12,500 15,000 20,000 25,000 30,000 35,000 CUSTOMERS VEHICLE INDEMNITY 10,000 12,500 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 9. EXCESS In addition to the standard policy excess of 250 do you require the following voluntary excesses? 250 500 10. DEMONSTRATION Do you require Demonstration Cover for an Additional Premium? Yes No This cover only applies when the prospective purchaser is accompanied at all times by the Policyholder or named driver covered for Motor Trade purposes. 11. DRIVER DETAILS - A copy of the driving licence is required for every driver Drivers Full Name Occupation Birth Type of UK Licence Held Full-Time Part-Time 1. Proposer - - - 2. 3. 4. Date passed UK Test Month/ Year Length of permanent & continuous residence in UK Relationship to Proposer Address (if different to that stated above) Tick Use Required 1. Proposer Postcode 2. Postcode 3. Postcode 4. Postcode Motor Trade SDP Commuting 12. DRIVERS HISTORY Please answer the following questions having specifically asked the individuals concerned. Have you or anyone who will drive: a) been involved in any motor accidents or made a claim (fault or non fault) during the last 3 years? Yes No b) been convicted of any motoring offence (other than parking) or any criminal conviction, or have a prosecution pending, or sustained a fixed penalty resulting in an endorsement of the licence? Yes No c) an uncorrected defect in vision or hearing, physical or mental infirmity, or suffered from diabetes, epilepsy or any heart complaint? Yes No d) been declined motor insurance or had a policy cancelled or special terms imposed? Yes No IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS PLEASE GIVE DETAILS BELOW AND OVERLEAF IF REQUIRED 2621/MTRR/PROPFORM/MAR14 P4/7
12a. ACCIDENTS AND LOSSES Name of Driver Accident/Loss Brief Details Third Party costs Own costs Did you recover your own costs 12b. CONVICTIONS, PENDING PROSECUTIONS, DISQUALIFICATIONS (Refer to Driving Licence if necessary) Name of Driver Offence Conviction Offence Code Penalty Points Licence Endorsed If the offence was alcohol related state level of reading in m gms/m ltre Length of Ban/Yrs/ Mnths Did accident occur 12c. DISABILITIES AND MEDICAL CONDITIONS (A medical report may be required) Name of Driver Receiving Treatment now Description of disability/condition Advised DVLA at Swansea 12d. GIVE DETAILS WHY DECLINED/CANCELLED/TERMS IMPOSED Name of Driver Details 13. INSURANCE HISTORY AND NO CLAIM DISCOUNT Name of Present/Previous Insurer Policy Number Type of Policy: Motor Trade Private Car Commercial Vehicle Motor Cycle Other Expiry Date Number of years claimed (You must provide evidence from insurers (not broker) to confirm your entitlement to NO Claims Bonus) Do you wish to protect your No Claims Discount Yes No GENERAL INFORMATION CANCELLATION REFUNDS You may cancel your insurance at any time by returning your Certificate of Motor Insurance. The cancellation will be effective from the date the Certificate is received by us and the appropriate refund will be calculated on a pro-rata basis less a 40 administration charge. Any refund will be subject to no claim having been made in the period since last renewal. WARNING Theft of and from vehicles in the UK is a major problem. You should ensure that every possible precaution is taken to avoid your vehicles becoming another victim of this crime. Do not leave your keys in unattended vehicles at ANY TIME or leave any of your vehicles unsecured whilst it is unoccupied. Failure to take these precautions could result in a claim not being paid. It is important that any driver who is likely to drive, must be disclosed on this Proposal Form. All accidents and convictions must be disclosed. Failure to do so could result in a claim not being paid. Upon making a claim you may be requested to provide evidence that you are in business in the motor trade. 2621/MTRR/PROPFORM/MAR14 P5/7
ADDITIONAL INFORMATION Please use this area if there is insufficient space on the form for any of your answers. Question No. Details IMPORTANT NOTES - QBE Insurance (Europe) Limited reserves the right to decline any Proposal or impose special terms. A copy of this Proposal will be issued to you if requested within 3 months of completion. You should keep a complete record of all information supplied to QBE Insurance (Europe) Limited, including copies of all letters. A specimen Insurance Document is available on request. Material Facts: When completing this Proposal Form, you must disclose to QBE Insurance (Europe) Limited all material facts and failure to do so could result in your policy being invalidated. Material facts are those which might influence the acceptance or assessment of your Proposal i.e. driving convictions, vehicle modifications. If you are in any doubt as to whether a fact is material, you should disclose it. Failure to do so may completely invalidate your Insurance and leave you without cover. It is an offence under the Road Traffic Act to withhold or suppress any material information, or to make a false statement to obtain motor insurance. Fraud Act 2006: If you provide an answer/information which you know is untrue you may be committing a criminal offence. You must also disclose all information which you know we would want to take into account in evaluating your Proposal (e.g. previous accidents). Failure to provide such information may be a criminal offence. These offences are punishable with up to 10 years imprisonment and/or a fine. Claims and Underwriting Exchange and Motor Insurance Anti-Fraud and Theft Database: Your details may be passed to the Claims and Underwriting Exchange Register (CUE) run by Insurance Database Services Ltd (IDSL) and the Motor Insurance Anti-Fraud and Theft Register (MIAFTR) run by the Association of British Insurers (ABI). We also exchange information with the Police and/or other Insurers and/or other organisations through various other databases. The aim is to help us check information provided and also to prevent fraudulent claims. Under the conditions of your Insurance Document with us, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers. Motor Insurance Database: Your policy details will be added to the Motor Insurance Database (MID), run by the Motor Insurers Bureau (MIB). 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 and the Motor Insurers Bureau may search the MID to obtain relevant policy information. Persons pursuing a 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 us or at www.mib.org.uk Data Protection: In addition to the above databases, your information, including any personal and sensitive information you have given, may be disclosed to Agents and Service Providers appointed by us, such as Claims Handling Agents, Approved Engineers and Investigative Agents. Your information may also be transferred to any country including countries outside the European Union, for the purpose of administration. Your information may be shared with other members of QBE Insurance Group. Information held about you may, with some exceptions, be obtained by application to the appointed Data Controller. QBE Insurance (Europe) Limited is a member of the QBE Insurance Group. QBE Insurance (Europe) Limited is Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Registration Number 202842. 2621/MTRR/PROPFORM/MAR14 P6/7
DECLARATION - I/We declare that to the best of my/our knowledge and belief the answers given on this proposal whether by me/us or on my/our behalf, are complete and true and that I/We have not withheld any material information. I/We undertake that the vehicle(s) to be insured will be kept in a roadworthy condition and will not be driven by any person who to my/our knowledge has been refused motor insurance or continuation thereof and will not be used for purposes other than those stated. If this proposal has been completed on my/ our behalf, I/We agree the person is deemed to be my/our Agent and not an Agent for QBE Insurance (Europe) Limited and that I/We have read the information provided before signing the form. I/We agree to your processing and disclosure of our personal and sensitive information as outlined in the IMPORTANT NOTES to this proposal and that this proposal is subject to English Law and shall be the basis of the contract between me/us and QBE Insurance (Europe) Limited. For your own benefit and protection you should read the important notes and declaration section of this proposal form carefully before signing. If you do not understand any point please ask for further information. Proposer s Signature If in company name, state position held Date The Underwriters reserve the right to decline any proposal. 2621/MTRR/PROPFORM/MAR14 P7/7 QBE European Operations is a trading name of QBE Insurance (Europe) Limited, no. 01761561 ( QIEL ), QBE Underwriting Limited, no. 01035198 ( QUL ), QBE Management Services (UK) Limited, no. 03153567 ( QMSUK ) and QBE Underwriting Services (UK) Limited, no. 02262145 ( QSUK ), whose registered offices are at Plantation Place, 30 Fenchurch Street, London, EC3M 3BD. All four companies are incorporated in England and Wales. QIEL and QUL are authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. QUL is a Lloyd s managing agent. QMSUK and QSUK are both Appointed Representatives of QIEL and QUL.