motor trade proposal form WHERE THIS FORM IS BEING USED FOR QUOTATION PURPOSES ONLY, PLEASE COMPLETE THE QUESTIONS SHADED. IN ANY OTHER CASES PLEASE ANSWER ALL QUESTIONS A full policy wording is available on request Please answer all questions. If there is insufficient space or you have ticked any of the shaded boxes, please use the additional information section on page 13 clearly indicating the question number to which the information relates. Please complete in capital letters using an ink pen. proposer Proposer s Full Name Trading Name Postal Address If you are a sole trader please state your Home Address Postcode Daytime Telephone Number Postcode If a limited company, please state Company Registration Number Directors or partners names in full (if not shown above) Period Insurance required from to 1
Details of Motor Trade ActivitIES It is important that you provide full details of your business activities in order that we can offer relevant covers at a competitive premium. Sale of Motor Vehicles Maintenance and Repair of Motor Vehicles Other Motor Trade Activities - please specify GENERAL QUESTIONS Please consider each of the General Questions carefully and answer each as fully as possible providing full details of dates and of Insurers and their policy numbers where appropriate. Failure to disclose all relevant information may invalidate the policy cover. 1. What is the length of experience you or any director or partner has had in the Motor Trade business? Years 2. What is the length of experience you or any director or partner has had in running a business? Years 3. Have you or any director or partner ever been declared bankrupt or insolvent? 4. Have you or has any director or partner ever been charged with or convicted of arson or any offence involving dishonesty of any kind? 5. In respect of any of the risks which you now wish to insure against: (a) Have you or has any director or partner (whether for this business or a previous one) held insurance in the last 5 years? (b) Has any previous insurer refused to provide cover or renew a policy, or imposed special terms or conditions? (c) Have you or has any director or partner (whether in this business or a previous one) ever been fined or given an improvement or prohibition order under the Health and Safety at Work Act 1974, the Consumer Protection Act 1987, the Environmental Protection Act 1990 or similar law? 6. Have you or has any director or partner (whether in this business or a previous one) suffered loss, destruction or damage, made a claim, or had any claim made against you or them during the last 3 years, for any risk that you wish to insure under the following Sections of cover? If you have answered YES to any of the above questions, please provide full details on pages 13 and 14 of this form trading addresses If wthere are more than two premises to be insured, please insert full details (including postcodes) of the additional premises under Additional Information below. Premises (1) Address: Premises (2) Address: Postcode 2 Postcode Please indicate which of the above is your main premises Premises (1) Premises (2)
ADDITIONAL INFORMATION road risks IMPORTANT: It is an offence under the Road Traffic Act to make a false statement or to withhold any material information for the purpose of obtaining a Certificate of Motor Insurance. Please ensure that all questions are answered correctly in every particular. Is cover required? 1. Please select level of cover comprehensive third Party Fire & Theft Third Party Only Please note that young or inexperienced drivers attract the following excesses in addition to the standard Accidental Damage excess: Drivers under 21 years of age: 300 Drivers over 21 but under 25 years of age OR Drivers who hold a provisional licence OR Drivers who have held a full licence for less than 12 months OR Drivers who do not hold a licence and are driving in circumstances where a licence is not required by law: 150 2. For Comprehensive cover, the standard excess is 250 in respect of Accidental Damage. Do you wish to amend this amount? If, then select either 2a) Do you wish this excess to also apply to each and every loss in respect of Fire, Theft and Windscreen damage? 100 500 3. Please state total number of Trade Plates. Where you have more than one premises please indicate which premises the individual vehicles operate from. courtesy Cars means vehicles lent by yourself to customers while their own vehicle is in your custody or control for repair service or maintenance. Private Hire Cars means vehicles provided with a driver by prior appointment. If the vehicles are controlled by radio or if they operate from a taxi rank, insurance cover is not available under the Excelerator policy and separate insurance arrangements should be made. AFVs means Agricultural and Forestry Vehicles. special Types means specialised vehicles such as fork lift trucks and vehicles used in construction e.g. excavators and dumper trucks. HGVs means Heavy Goods Vehicles with a Gross Vehicle Weight in excess of 7.5 tonnes. If there is insufficient room to provide details of all the vehicles please list them on a separate sheet. If there are more than two premises to be insured, provide details under the various sub-headings on page 4. 3
4. Details of all Motor Vehicles owned and registered or leased in the name of the proposer. 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 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. CARS 1 2 3 4 5 6 make Model (incl. CC and fuel type) Premises (1 or 2) Courtesy cars 1 2 3 4 5 make Model (incl. CC and fuel type) Premises (1 or 2) private hire CARS 1 2 make Model (incl. CC and fuel type) Premises (1 or 2) other motor vehicles VEHICLE TYPE NUMBER Premises (1 or 2) Goods Carrying Vehicles up to 7.5 tonnes Motorcycles AFV s Special Types HGV s over 7.5 tonnes Minibuses & Coaches Breakdown & Recovery Others (please specify) 5. Does the value of any one vehicle exceed 50,000? 6. Do you wish to restrict driving (maximum of four named persons)? a) If YES, please provide details of all persons who may drive (incl. Principals, Partners and employees). 1 2 3 4 name date of birth 4
b) If NO, please indicate the number of drivers within the given age groups 17-24 YEARS 25-29 YEARS 30-39 YEARS 40-49 YEARS 50 YEARS + AGE GROUP NUMBER OF DRIVERS If you have ticked any of the shaded boxes, please provide details in the Additional Information Section on page 13 of this form Please consider very carefully and provide full details. Failure to disclose all relevant information may invalidate the policy cover. c) Have YOU or any DIRECTOR or PARTNER (whether under a current or previous trading name or interest) or has ANY PERSON who to your knowledge will drive the vehicle(s) i) in the past 5 years been convicted of ANY motoring offence including Endorsable Fixed Penalty Motor Offences or is any such prosecution pending? ii) at any time been refused insurance or quoted an increased premium or had special terms imposed? iii) been disqualified from driving? iv) at any time suffered from any heart complaint, diabetes, fits or any other physical or mental infirmity or are you/they regularly taking any prescribed medication? If YES, has the health condition been notified to the Driver Vehicle Licensing Agency (DVLA)? v) if the health condition has been notified to the DVLA, have they issued the driver with a licence? 7. Do you wish to exclude cover for the following? a) Loan/Hire to Customers b) Accompanied Demonstration or Tuition 8. Do you wish to restrict Social, Domestic and Pleasure use to principal partners, directors and employees? If any of the vehicles to be insured under this policy are also used for another business of yours, the Road Risks Section of the policy can be extended to cover this separate business use. 9. Is separate Business Use required? If, provide details of the other business use in the Additional Information Section 10. Do you specialise in sales or servicing of high group cars, HGV s or mini buses/coaches? 11. Do second hand car sales account for more than 50% of your turnover? 12. Is your business solely involved in vehicle body repairs? 13. Will the vehicles be used at any time on any part of a commercial or military airport or airfield? 14. Do you undertake any work outside of Great Britain, rthern Ireland, the Isle of Man or the Channel Islands? If you have ticked any of the shaded boxes, please provide details in the Additional Information Section on page 13 of this form PROPERTY SECTION Is cover required? 1. Standard cover includes theft cover. Do you wish to exclude theft cover? 2. If YES do you require glass cover? If YES, please specify value of glass at risk (subject to a minimum of 5,000) If there are more than two premises to be insured, provide details of the required sums insured under the various sub headings shown. 3. PROPERTY TO BE INSURED: PREMISES 1 PREMISES 2 AT THE PREMIses SUM INSURED sum INSURED The sums insured must reflect the cost of rebuilding making appropriate allowance for Architects / Consultants fees. (a) Buildings including: Landlords fixtures and fittings, glass, fixed signs, walls, fences, gates, forecourts, canopies, outbuildings 5
The sums insured must reflect the replacement value as new of machinery and plant. Also include the value of fuel installations but not fuel held in them. (b) general Contents including, Machinery, Plant, fuel installations and all other contents for which you are responsible excluding that shown below. (c) Computer equipment (excluding autotuning equipment) (d) stock of tobacco, cigarettes, wines and spirits, audio and visual equipment Vehicle includes your own or leased in by you those for sale and those of your customers while in your custody or control and the sum insured should reflect values at peak periods. (e) Stock of Motor Vehicles Include value of fuel stocks in All other stock. (f) all other stock (together with materials in trade for which you are responsible) (g) refrigerated stock (Min Sum Insured 500-Max Sum Insured 2,500). Complete if more than 500 worth of cover required NB. Cover does not apply to refrigerated equipment greater than 10 years old AWAY FROM THE PREMIses sum INSURED If you require cover to be more than standard minimum limit of 2000 then insert the revised limit you require and detail the maximum number of vehicles used. (h) Stock in transit per vehicle (Minimum Sum Insured 2,000). (i) How many vehicles are used for the carriage of such stock? If you require cover to be more than standard minimum limit of 2000 then insert the revised total limit you require. (j) Portable hand tools, mobile pagers, telephones, (Minimum Sum Insured 2,000). 4. Property Damage Excess - The first 250 of each and every loss is excluded from cover, do you wish to amend this amount? If YES, then select either: 100 500 1,000 2,500 5,000 5. theft Excess - The first 250 of each and every loss is excluded from cover, do you wish to amend this amount? If YES, then select either: 100 500 1,000 2,500 5,000 6. Please provide the name and address of any company or person who has a financial interest in the property to be insured under this Section. This will be noted on the policy. Name: Address: Postcode 7. Do any of the buildings you occupy have walls that are not made of brick, stone or concrete, or roofs that are not made of slate, tile, concrete, metal or asbestos? 8. are your premises including walls, gates and fences in good repair and is your equipment and machinery properly fenced, guarded and maintained? 9. Do you have lifts, cranes, hoists, boilers, steam containers or other pressure vessels? 6
If YES, (a) Are they inspected to make sure they meet all legal requirements This service can be provided by RSA Engineering. Please see Page 12 of this form. (b) Please provide the name and address of the company that carries out legal inspections Name: Address: Postcode Questions 10-12. If you answer YES to any of these questions then please provide full details so that we can accurately evaluate the risk. 10. Do you carry out any other business or does any other business occupy or work from your premises? 11. Do you use burning, paint spraying or welding equipment at your premises? 12. are your premises heated (totally or partly) by a paraffin, waste oil or LPG (Liquified Petroleum Gas) appliance or system? BUSINESS INTERRUPtion Is cover required? The cover provided will be on the same basis as the PROPERTY Section (either including or excluding theft cover as selected) 1. Estimate of Annual Gross Profit The Maximum Indemnity period you choose must be long enough to allow for any required rebuilding/refurbishment of your premises and the time needed for your business to return to normal trading. 2. Please select Maximum Indemnity Period 12 Mths 18 Mths 24 Mths 36 Mths 48 Mths If you have ticked any of the shaded boxes, please provide details in the Additional Information Section on page 14 of this form Consider the total amount of outstanding debit balances you might have at any one time making due allowance for accountants fees incurred when claiming. If you require more than 50,000 of cover insert the total value required. Your policy will contain a condition that you should keep a quarterly record of the total amount you are owed and that a copy of this is kept away from your premises 3. Outstanding Debit Balances. 4. this cover does NOT include cover for failure of public supplies of electricity, gas or water. Do you wish to include this cover? MONEY Is cover required? Your estimate as well as cash should include the value in transit of any uncrossed cheques, uncrossed giro cheques, uncrossed bankers drafts, uncrossed money orders, uncrossed postal orders, unused national savings certificates and unused units in franking machines 1. Estimated Annual Cash Carryings by: (a) Own Employees (b) Security Company Please provide full details of any safe you use to hold more than 1000 so that we can determine its quality and suitability for the amount of money you want to hold in it. 7
2. cash in Safes. Policy cover includes up to a total of 1,000 in unspecified safes. If you require more than 1,000, the safes must be specified. Please provide details below: 1 2 3 4 make Model serial no. limit wrongful conversion Is cover required? This cover is only available as an extension to Money Insurance. Cover is subject to the Proposer obtaining from H.P. Information Ltd. written confirmation that each vehicle that is to be purchased is not subject to a Hire Purchase interest or Contract Hire Agreement. The Standard limit of cover is 10,000 which is the total amount payable in respect of all vehicles bought by you in any one period of insurance. 1. Do you wish to amend the the Limit of Indemnity to 50,000? 2. Are purchase transactions of second hand vehicles accurately recorded? 3. Please insert Estimated Annual Turnover of second-hand vehicles including allowance for part exchange values. personal accident Is cover required? Explanatory notes (i) 24 hour worldwide cover is available for proprietors, partners, directors or employees who are over 16 and under 65 years of age. (ii) cover applies either to different groups of persons depending upon their business duties or to individual named persons up to a maximum of 10. Complete either Question 1 or 2 as appropriate. (iii) Classification of employee s main duties management class 1 clerical / Administration only class 2 sales & Valeting of Motor Vehicles, Drivers and Petrol Sales class 3 maintenance & Repair (exc HGV s, welding & paint spraying) CLASS 4 maintenance & Repair (inc HGV s, welding & paint spraying) class 5 (iv) You may restrict cover for any or all Insured Persons to accidents arising out of and in the course of employment by you. (v) You can choose cover up to a maximum of ten units with one unit of cover comprising the following benefits:- 1 Death 10000 2 Loss of Limbs or Sight 10000 3 Permanent Total Disablement 10000 4 Temporary Total Disablement 100 per week 5 Temporary Partial Disablement 50 per week 6 Medical Expenses 15% of total of benefits paid under 4 & 5 1. If cover is required on a group basis for any of the persons to be insured, please complete the following NO. OF PERSONS NO. OF units Is cover limited to accidents of occupation only CLASS 1 CLASS 2 CLASS 3 CLASS 4 CLASS 5 8
2. If cover is required on an individual basis for any of the persons to be insured up to a maximum of 10, please complete the following: 1 2 3 4 5 6 7 8 9 10 Name date of birth 9 main class no. of units 3. Is any person to be insured suffering from ill health or a disability? 4. Has any person to be insured suffered an accident during the past 3 years resulting in either:- (a) loss of use of limb(s) or eye(s) or permanent disablement? (b) temporary disablement for more than 7 days? 5. For any person to be insured has any insurer ever (a) declined a Personal Accident proposal? (b) declined to renew a Personal Accident Insurance Policy? (c) imposed special terms on a Personal Accident Insurance Policy? liability Is cover required? If YES, questions 1-3 must always be answered Employer s liability Is cover required for your legal liability for injury to employees? If YES, complete SECTION A public liability Is cover required for your legal liability arising out of your business for injury to or damage to property of (members of) the public? If YES, complete SECTION B Is cover limited to accidents of occupation only If you have selected Public Liability cover, do you require cover for your legal liability arising out of goods sold or supplied by your business? Please consider very carefully and provide full details. Failure to disclose all relevant information may invalidate the policy cover. 1. Do you handle, use or store radioactive substances or devices, chemicals, gases, explosives, asbestos, silica or material containing silica or any other dangerous substance? 2. Do you accept, or have you accepted under contract, any contract clause which extends your common law liabilities? 3. Do you use any process which does or could result in the escape or discharge of substances which could cause pollution or contamination to:- (a) Buildings? (b) Other structures? (c) Water or land? (d) The atmosphere? If you have ticked any of the shaded boxes, please provide details in the Additional Information Section on page 14 of this form
SECTION A Explanatory notes (i) Classification of employees main duties management class 1 clerical / Administration only class 2 sales & Valeting of Motor-Vehicles, Drivers and Petrol Sales class 3 maintenance & Repair (exc HGV s, welding & paint spraying) CLASS 4 maintenance & Repair (inc HGV s, welding & paint spraying) class 5 (ii) total Annual Wages/Earnings includes overtime, value of board and lodgings, housing, accomodation, bonuses, other payments in kind or money received by all persons working under contracts of service (including directors) or any person supplied to or hired or borrowed by the Proposer before deduction for National Insurance, Income Tax, holidays with pay and contributory pensions. consider all employees duties and allocate each employee to the most appropriate of the five classifications shown and then insert details of the numbers of staff and their wages/earnings split between those employed on a full or part-time basis. 1. Full Time - of persons / wages / earnings by occupation class CLASS 1 CLASS 2 CLASS 3 CLASS 4 CLASS 5 NO. OF PERSONS total wages / earnings 2. Part Time - of persons / wages / earnings by occupation class CLASS 1 CLASS 2 CLASS 3 CLASS 4 CLASS 5 NO. OF PERSONS total wages / earnings SECTION B Please try to divide Estimated Annual Turnover as accurately as you can between the various business activities so that we can accurately evaluate the risk and provide a competitive premium. 1. Estimated Total Turnover for the forthcoming year split:- (a) Sales of New vehicles Turnover (d) repair / Service / Turnover Maintenance of Vehicles (b) Sales of Used vehicles Turnover (e) other (eg. Valeting of Turnover (c) Sales of Other Goods Turnover Motor Vehicles) Total Turnover 2. Is cover for Repair / Service / Maintenance to customers vehicles required? 3. Is cover for work away from your premises required? If YES, please state (a) wages involved in work away from the premises (b) whether this involves the use of heat If you opt for a lower Limit of Indemnity a discounted premium will be charged. 4. The standard Limit of Indemnity is 5m. Do you wish to decrease this limit? If YES, then select either 2m 1m 5. Do You (a) have any representation in the USA or Canada? (b) export or have you exported or plan to export in the future goods directly or indirectly to the USA or Canada? If you have ticked any of the shaded boxes, please provide details in the Additional Information Section on page 14 of this form 10
ENGINEERING SECTION Is cover required? If YES, please indicate below whether Inspection and Insurance cover is required If cover is required a separate policy will be issued by RSA Engineering. Please note that the cost of engineering inspection and insurance cannot be paid by instalments and should be settled in full. Please provide full descriptions of the plant to be insured so that each is separately identifiable. i) Full details of the plant and the process will be required for any LEV plant (dust extraction) ii) For any petrol pump installation, only the Pump and Motor can be insured for breakdown risks Please note that insurance cover is only available if inspection is selected. 1. Give details of plant to be covered plant description BOILER / PRESSURE VESSELS Air Receiver Pressure Vessel Steam Cleaner / Pressure Washes Other Boiler Plant (identify each item on a separate sheet) LIFTING EQUIPMENT Manual Chain Block Manual Pul Lift Manual Trifor Manual Winch Power Driven Chain or Rope Block Power Driven Winch Manual Crane - all types Sheerlegs Power Driven Vehicle Lifting Table - all types Lifting Jacks - all types Lifting Tackle (Chain Slings, Rope Slings, Hooks, Shackles, Runway Trolley) Runway Track or Beam Portable Gantry or A-Frame Passenger / Goods / Car lifts Other Lifting Equipment (identify each item on a separate list) ELECTRICAL PLANT Petrol Pump Installation Motor & Compressors Gas / Oil Burners Battery Chargers LEV Plant (Dust Extraction) Other Electrical Plant (identify each item on a separate list) premises (1 OR 2) inspection NO. OF ITEMS insurance NO. OF ITEMS 2. Has any accident, breakdown or explosion occurred to the plant in the last 3 years? 3. Please advise details of a contact for the purpose of arranging the engineering inspection Name: Daytime Telephone Number: If you have ticked to Question 2, please provide details overleaf. 11
road risks claims details date FULL DETAILS OF INCIDENT AND ANY INJURY OR DAMAGE PAYMENTS PAID OR CURRENT ESTIMATED COST other claims details date FULL DETAILS OF INCIDENT AND ANY INJURY OR DAMAGE PAYMENTS PAID OR CURRENT ESTIMATED COST 12
additional information 13
supplementary information 1. Are all external doors protected by steel shutters? 2. Are all accessible windows protected by steel shutters, grills or bars 3. Are the premises protected by an intruder alarm? (a) Please provide details of the installer? (b) Is the alarm NACOSS approved and maintained? (c) Is Redcare remote signalling used? (d) Is Level 1 Police response (i.e. immediate) expected in the event of an alarm activation? 4. Is Computer Equipment: (specifically computers) secured b (a) Individual metal enclosures or similar devices (b) Removal to secure area out of business hours 5. Are the premises protected by (a) CCTV, or security manning during business hours? (b) 24 hour on site security? 6. Have the premises and other premises adjacent or in the vicinity been free of arson / malicious damage in the past 12 months? 7. Is there an agreed and enforced Health & Safety Policy in operation 8. Is protective clothing and equipment supplied and its use enforced 9. Is there an enforced Smoking Policy in operation? 10. Are there maintenance programmes in force for: (a) Buildings? (b) Electrical Installation? (c) Plant / Equipment? (d) Fire Extinguishing Appliances? 11. Are vehicles left overnight on the premises, left within a secure compound? 12. Are flammable liquids, gases and substances kept in secure store and only withdrawn as required? 13. Have you been established at your current premises for five years or more? 14
important information Please read the following carefully before you sign and date the Declaration. 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 fulfiled 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 1974. You should also keep your own record (including copies of letters) of all information supplied to us in arranging this insurance. The Insurers reserve the right to confirm driving licence details with DVLA. 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 registers. 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 www.miic.org.uk. You should show this notice to anyone insured to drive the vehicles covered under this policy. customer 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 and that the vehicle(s) is/are in a sound and roadworthy condition and that 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 understand that the vehicle(s) to be insured shall not be driven by any person who to my/our knowledge has been refused insurance or continuance thereof. I/We declare that this Proposal Form 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. Signature of Proposer(s) 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. Signing this Proposal Form does not bind the Proposer or the Insurer to complete this insurance. Please initial any alterations on this Proposal Form. 15
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. UKC04630 november 2012