Combind Motor Trad Proposal
Combind Motor Trad Insuranc Proposal Policy Numbr PLEASE ANSWER ALL QUESTIONS IN BLOCK CAPITALS 1 Nam of Proposr in full: Addrss or Rgistrd Offic: 2 Businss or occupation: (if mor than on, stat all) 3 Plas dscrib th full xtnt of your Motor Trad activitis (.g. vhicl sals, rpair, srvicing, tsting, braking, sal of ful, filling station propritor tc.) 4 Situation(s) of proprty to b insurd: (if diffrnt from postal addrss) 1. 2. 5 SIMI Mmbrship No: 6 In addition to SIMI ar you a mmbr of any othr motor trad association? (If Ys, which?) FOR OFFICE USE ONLY Priod of insuranc FROM Tim Tim TO Rnwal Dat Ara/Branch Ara/Branch Numbr Agncy Agncy No. & Chk Ltrs Not: Th insurr with which your contract will b concludd is Aviva Insuranc Limitd ( th Company ). Th insuranc will not b in plac until th proposal has bn accptd by th Company. Th Company rsrvs th right to dclin any proposal. If you would lik to xamin th covr in mor dtail a spcimn policy is availabl fr on rqust. important: As is it an offnc undr th Road Traffic Act to mak any fals statmnt or withhold any matrial information for th purpos of obtaining a Crtificat of Insuranc, grat car should b takn to nsur that all qustions and subsctions of qustions ar answrd fully and accuratly. If th proposr is a firm or privat company, th qustions ar to b rad and answrd as also applying to ach individual partnr or mmbr. PF.030.11.12
Sction 1 Matrial Damag 1A Commrcial All Risks Itm No. Proprty to b Insurd Sum Insurd 1 Building including: (a) Landlord s fixturs and fittings (b) Kiosks, outbuildings and annxs (c) Walls, fncs, gats, forcourts, canopis and fixd signs 2 Machinry, plant, including ful installations, and all othr contnts blonging to you or for which you ar rsponsibl 3 Stock and matrials in trad (x. Motor Vhicls) blonging to you or for which you ar rsponsibl (Limit Radios/Audio/Visual Equipmnt s6,500) 4 Stock of tyrs s 5 Stock of Shop Insurd (Excluding win, spirits, cigartts or frozn food) 6 Wins and spirits s 7 Cigartts/Tobacco (Limitd to s6,500) s 8 Vhicls th proprty of th insurd or lasd in by th insurd or hld in trust for which thy ar rsponsibl s (Including Customr s Vhicls) 9 Portacabin s 10 All Othrs (Plas spcify) s s s s s Total Sum Insurd s Glass: If th building is not to b insurd undr this sction indicat if you wish to insur Glass forming part of th buildings. Not: If th building is insurd undr Itm No. 1 abov Glass will b automatically covrd. or A CONSTRUCTION Ar all th buildings constructd of brick, ston or concrt and roofd with slat, til, mtal, asbstos, cmnt shts or concrt? If, giv dtails E OTHER INTERESTS Is any othr party (.g. loan company) intrstd in any itm of this sction? If, giv dtails. BUILDINGS / CONTENTS / STOCK / OTHERS (plas circl itm). Nam & Addrss of Intrstd Party: B HEATING C Do you us any artificial mthods of hating or lighting? If, giv dtails Occupancy To what xtnt will your prmiss b lft unoccupid? by day by night Not 1: Not 2: Not 3: Owing to th ffcts of th avrag claus, applicabl to ach itm abov, sums insurd should rprsnt th full valu of th proprty insurd. Profssional fs ncssarily incurrd in rinstating buildings and machinry ar automatically insurd, providd sufficint allowanc is mad in fixing th sums insurd on buildings and machinry rspctivly. Fir Brigad chargs automatically includd up to a limit of 25,000. D Scurity (Whn your prmiss ar closd to customrs and callrs, or ar lft unoccupid) (i) Ar all xtrnal doors, windows and othr opnings scurd? (ii) Do you hav an intrudr alarm? (if ys plas forward a copy of alarm spc.) (iii) Was it installd by an NSAI rgistrd alarm company? Nam of company (iv) Is it connctd to a cntral station? 1B Additional Covrs Plas tick if rquird. Staling Covrs loss or damag as a rsult of forcibl and violnt ntry or xit. Sums insurd as pr sction 1A
Sction 1 Matrial Damag (continud) mony and assault Covrs loss of mony by any caus whatsovr and compnsation for dath or injury following assault of any prson in charg of mony or stock. DO YOU REQUIRE COVER. IF PLEASE ANSWER THE FOLLOWING QUESTIONS: 1 What limit of indmnity do you rquir in rspct of mony comprising cash, chqus and othr ngotiabl instrumnts (xcluding crossd chqus and othr non-ngotiabl mony)? Limits of indmnity (d) (a) In th prmiss out of businss hours scurd in a lockd saf or strongroom. (standard covr 6,500) (b) In th bank night safs until at bank s risk. (standard covr 26,000) (c) Any othr loss including whilst in transit or whilst in th prmiss during businss hours. (standard covr 13,000) In th custody of th Ptrol Pump attndants/shop assistants btwn th hours of 8.00pm and 8.00am (maximum availabl limit 500) 3 Do you wish to incras th lvl of bnfit for assault? Standard Covr, capital 313000, Wkly 3130. If, giv dtails: 4 Plas complt dtails of saf(s) blow: Mak/Modl Dimnsions How anchord Limit 2 What is th stimatd annual amount of lodgmnts and withdrawals of such mony carrid btwn prmiss and th bank? ACCIDENTAL DAMAGE TO MACHINES Covrs loss or damag by fir, thft or accidntal xtrnal mans, of slctd machins or quipmnt lswhr than at th Prmiss. DESCRIPTION OF MACHINES OR EQUIPMENT SUMS INSURED Itm 1 Itm 2 computrs Covrs accidntal loss or damag to computrs, R-instatmnt of Data of I.C.O.W. 1 Computr(s) dtails, (if laptop plas advis). NAME OF MANUFACTURER TYPE/MODEL. YEAR OF MAKE NEW REPLACEMENT VALUE 2 Ar your computrs subjct to a maintnanc contract providing for fr parts and fr labour in th vnt of a brakdown? frozn foods (This sction rlats to Frzr Cabints only). Is this sction rquird? Covrs dtrioration of frozn foods rsulting from (a) brakdown of rfrigration plant du to its own inhrnt dfct. (b) accidntal failur of public supply of lctricity and (c) scap of rfrigrant or fums. Dscription of Plant and makrs numbr; Makrs nam & dat of manufactur SUM INSURED (max. valu of stock) 1 Is thr a currnt manufacturr s guarant warranty on th plant 2 Is thr a currnt maintnanc contract on th plant and will this b kpt in forc
Sction 2 1 Is this sction rquird? This sction covrs loss of profit through intrruption of th businss following any of th prils slctd undr th Matrial Damag sction 1A - and Staling if includd. Gross Profit (including 100% of Payroll) Incras in cost of working Tax rlif Businss Intrruption Th Policy provids covr up to 13,000 for ach of th following xtnsions at no xtra charg. Supplir s xtnsion Customr s xtnsion Contract sits Prvntion of accss Public utilitis Loss of attraction. If a highr limit is rquird, plas advis dtails. Rnt Rcivabl Book dbts Priod for which indmnity is rquird: conscutiv months following th dat of th damag. (If longr than 12 months thn sums insurd should b adquat to catr for th priod slctd). Sction 3 Employrs Liability Is this Sction rquird? Standard limit of indmnity 13 million. Employ, is dmd to includ:- any dirctor, xcutiv dirctor or partnr of th insurd ngagd in th businss; a mmbr of th insurd s family ngagd in th businss; any prson mployd by th insurd undr a contract of srvic or apprnticship; labour mastrs and prsons supplid by thm; prsons mployd by labour only sub-contractors; slf-mployd prsons; drivrs and/or oprators of plant hird to th insurd; prsons gaining work xprinc; any othr prson hird or borrowd by th insurd. Th total rmunration of th abov must b includd. Rmunration mans:- Gross wags, salaris, commission or fs including ovrtim, bonuss and all prrquisits and bnfit-in-kind (but not mployr s PRSI contributions), board and/or lodging, housing accommodation, housing subsidy, company car, mployr s contribution to pnsion or similar fund and mployr s contribution to any insuranc schms arrangd for th bnfit of mploys. Gross wags tc. should includ:- Employ s contribution to PRSI, Employ s contribution to pnsion or similar funds or insuranc schms and PAYE tax. Turnovr mans gross turnovr without any dduction and inclusiv of Valu Addd Tax. Full contract pric must b includd without any dduction. mploy numbrs and rmunration Plas stat th numbrs of prsons mployd and thir stimatd annual wags, salaris and all othr arnings for th nxt 12 months undr th following hadings. Th figur should includ a minimum of 21,000 for ach full tim mploy. Dscription No. Part/Tim No. Full/Tim Estimatd Annual Rmunration Employs Clrical/Sals Mchanics LCV s Mchanics HGV s Shop Assistants Ptrol Pump Attndants Proprty rpairs Partnrs Clrical/Sals /Dirctors Mchanics Othrs
Sction 3 EMPLOYER S LIABILTY Employrs Liability (continud) 1 Dscrib prcisly: (a) Work undrtakn at your prmiss (b) Work undrtakn away from your prmiss 2 Hav you ntrd into any agrmnt assuming a liability for injury, illnss, loss or damag for which you would not hav bn liabl in th absnc of such an agrmnt? If, plas supply a copy of th agrmnt. 3 Do you undrtak oprations outsid th Rpublic of Irland, Grat Britain, Northrn Irland, th Channl Islands or th Isl of Man? if, giv full particulars, including countris concrnd, natur of activity, wags and xpnditur. 4 Do any of your activitis involv xposur to nois lvls xcding 85-dB (A)? If, giv full particulars. 5 Ar any of th following usd in your businss? if, plas giv dtails. (a) asbstos, silica or othr substanc involving a halth hazard. (b) radioactiv substancs or othr sourcs of ionising radiations. (c) flam cutting or wlding plant or othr hat producing plant or procsss AWAY from your own prmiss. 6 Hav you prpard a writtn safty statmnt in accordanc with th Safty, Halth and Wlfar at Work Act 2005 and Safty, Halth and Wlfar at Work Gnral Application Rgulations 2007? (a) (b) () If not, you should do so immdiatly in th intrst of safty and to avoid proscution. To assist you, th information booklt Guidlins on Safty Statmnts is obtainabl from any offic of th Halth and Safty Authority. Our Risk Managmnt srvics unit can advis you on th prparation of a Safty Statmnt and th implmntation of a safty policy. Th Halth and Safty Authority also provid guidanc publications on safty statmnts.
Sction 4 Road Risks, Public and Products Liability Risks Road RiskS Is this Covr rquird? This sction provids th ncssary Third Party covr you must hav by law for us of vhicls ownd by you or for which you ar lgally rsponsibl with an option to includ Fir and Thft and Accidntal Damag to such vhicls. Covr is xtndd to includ vhicls usd for dmonstration or tuition purposs whilst prospctiv customrs ar accompanid by you/your mploy. Whilst th standard covr is for vhicls usd in connction with your businss, us for social, domstic and plasur purposs by spcifid drivrs will b considrd if thy work in th businss and us vhicls ownd by th proposr. In th vnt that th Insurd Vhicl is damagd byond conomic rpair, w will calculat th valu of th Insurd Vhicl at th tim of th loss on th basis of th currnt markt valu (for a vhicl of th sam mak and modl) or whr applicabl th limit of th valu (sum insurd) placd by you on th Insurd Vhicl as shown on th policy schdul, whichvr is lss. Plas not: W will not pay for loss or damag ovr th currnt markt valu vn if th sum insurd on th policy schdul may b gratr. TE: Vhicls in th following class should not b includd, as any insuranc rquird for ths must b sparatly arrangd. Vhicls usd for Public/Privat Hir or Slf Driv. l Goods carrying vhicls usd for hir or rward. l Vhicl Transportrs carrying thr or mor vhicls. l Vhicls blonging to individual partnrs or dirctors unlss spcifid by th Company. l Vhicls blonging to mploys. l Vhicls in which a partnr or dirctor or an mploy is intrstd undr a hir purchas agrmnt unlss spcifid by th Company. l Any othr vhicl usd othr than for Motor Trad purposs. 1 Ar you insurd or hav you vr bn insurd in rspct of any motor vhicl including motor vhicl road risk? If Ys, plas stat th nam of vry insurr concrnd 2 Ar you ntitld to a No Claims Discount from your prvious insurrs in rspct of any of th covrs now proposd for? If Ys; (a) Plas stat numbr of yars. (b) Plas provid proof. 3 Full particulars of all purposs for which th vhicl(s) will b usd. 4 Stat undr ach of th following classs th total numbr of vhicls ownd by you for th purpos of sal, also vhicls bing acquird by you undr a hir purchas agrmnt. (i) Privat Cars (ii) Commrcial Vhicls (iii) Motor Cycls 5 Dscription of all othr vhicls (i.. Brakdown/Own Goods Carrying vhicls/motor Cycls) ownd by you and usd solly in connction with your businss as a Motor Tradr. Carrying Proposrs stimat of prsnt Rgistrd lttrs Mak and modl of vhicl Typ of body Yar of capacity valu including accssoris and numbr to b insurd manufactur or H.P./C.C. and spar parts 6 Ar you an accrditd Rcovry Agnt for any Motoring Organisation? If any vhicl availabl for such rcovry srvic must b includd Numbr of Rcovry Vhicls 7 Stat scop of covr rquird undr this sction i.., Comprhnsiv or Third Party, Fir & Thft or Third Party Only 8 What is your National Flt Databas uniqu idntity numbr?
Sction 4 Road Risks, Public and Products Liability Risks (continud) 9 Giv full dtails of all prsons who may driv for th following purposs. (i) Businss us only - Cod A (ii) Businss and social domstic and plasur - Cod B (iii) Social/domstic and Plasur only - Cod C Has any Drivr a proscution pnding or Nam of Drivr Typ of licnc currntly hld and Dscription Ag Occupation any Pnalty Points imposd on thir Rcord of Hav any insurrs vr Has h/sh dfctiv Country of Issu of us Cod (If not mployd in th licnc or vr bn convictd of any Accidnts/Claims rfusd or canclld or vision or haring or (.g. Full, Provisional tc.) (A), (B) proposr s garag plas motoring offnc or had his/hr licnc during Past 5 yrs dclind to rnw his/hr suffrd at any tim from or (C) stat occupation and rlationship suspndd? If so, stat Dat of Offnc, of driving motor insuranc or Diabts, fits or hart to proposr) Offnc Typ and Numbr of Pnalty imposd spcial trms? complaint or infirmity? Points Total Total If so, giv full particulars If so, stat dtails Numbr Cost 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Sction 4 Road Risks, Public and Products Liability Risks (continud) Public and Products liability Risks Ar ths covrs rquird Public Liability Products Liability 1 Plas stat your projctd turnovr figurs, which ar to b inclusiv of V.A.T., for th nxt 12 months undr th following hadings: Cars/Light Havy Buss/ Othrs Commrcials Commrcials Coachs (spcify) Sals of nw vhicls Sals of usd vhicls Srvicing/Maintnanc/Rpair Sal of spar parts/accssoris Ptrol Sals Tyr Fitting/Sals Las Hir Activity All Othrs Spcify blow 2 Giv capacity of prmiss rckond in numbr of vhicls undr ach of th following hadings. Showroom ara Garag Ara Workshop Ara In th opn 3 Ar th prmiss usd for any purpos othr than that of a showroom, garag, workshop or forcourt? If plas stat such othr purposs 4 If you hav Inspction Pits, ar thy guardd/closd ovr whn not in us? 5 If you hav car wash facilitis plas stat numbr of bays/booths 6 Your Activitis: Do You (a) Hold a dalrship appointmnt for a particular marqu? If, plas stat which? (b) Export vhicls? If, plas stat turnovr and countris concrnd? (c) Import vhicls? If, plas stat turnovr and countris concrnd? (d) Undrtak or spcialis in (i) (ii) (iii) (iv) (v) th sal or rpair of commrcial vhicls, public srvic vhicls, agricultural vhicls or contractors plant? vhicl body building? vhicl braking? th manufactur or r-manufactur of vhicl parts and accssoris? any othr activity at or from th prmiss? If to any of abov, plas giv full dtails and th prcntag as a proportion of ovrall activitis.
Sction 4 Road Risks, Public and Products Liability Risks (continud) 7 Dscrib prcisly: (a) Work undrtakn away from your prmiss (b) Goods supplid, installd, rctd, rpaird, altrd or tratd by you 8 Hav you ntrd into any agrmnt assuming a liability for injury, illnss, loss or damag for which you would not hav bn liabl in th absnc of such an agrmnt? If, plas supply a copy of th agrmnt. 9 Do you us Sub-Contractors? If so giv dtails. 10 How do you nsur that any sub-contractors mployd by you maintain adquat liability insuranc? 11 Hav you prpasd a writtn safty statmnt in accordanc with th Safty, Halth and Wlfar at Work Act 2005 and Safty, Halth and Wlfar at Work Gnral Application Rgulations 2007? If not, you should do so immdiatly in th intrst of safty and to avoid proscution. To assist you, th information booklt Guidlins on Safty Statmnts is obtainabl from any offic of th Halth and Safty Authority. Our Risk Managmnt srvics unit can advis you on th prparation of a Safty Statmnt and th implmntation of a safty policy. Th Halth and Safty Authority also provid guidanc publications on safty statmnts. Sction 5 Lgal Protction W provid covr for this Sction automatically Sction 6 Prsonal Accidnt Is this sction rquird? (All your mploys must b covrd if sction rquird) Furthr Dtails 1 To your bst knowldg and blif is ach prson to b insurd in good halth and fr from physical and mntal dfct? If plas giv dtails 2 Will prsons to b insurd travl ovrsas on your businss? If plas giv dtails of countris likly to b visitd 3 Plas giv dtails of all injuris and srious illnsss suffrd by any prson to b insurd during th last 5 yars: Estimatd numbr of prsons to b insurd Dscription Estimatd No. Managrial sals and clrical mploys not working manually in th businss All othr mploys Covr & Bnfits 1 Covr is on 24 Hour accidnt basis 2 Bnfits ( plas spcify) (A) Capital Sums: Dath Loss of limb(s) or y(s) Prmannt total disablmnt (b) Capital Sums Tmporary total disablmnt
Sction 7 Profssional Indmnity Is this Sction rquird? (NB: Plas not this covr is in rspct of th provision of advic or srvics by th Proposr in rlation to any Insuranc Mdiation Activity in connction with any insuranc product rlating to a Motor Vhicl ONLY). (i) Hav you or ar you in th procss of rgistration with IFSRA? (ii) IFSRA Rgistration Numbr (iii) Businss for th purpos of this Profssional Indmnity Insuranc? Th provision of advic or srvics by th Proposr in rlation to any Insuranc Mdiation Activity in connction with any insuranc product rlating to a Motor Vhicl. (iv) Plas provid dtails of th firm s rtaind insuranc incom blow Annual Incom Rtaind Incom Crditor Protction Insuranc # # GAP & Vhicl Asst Protction # # Insurd Warrantis and Extndd Warrantis # # Tyr and Exhaust Insuranc # # MOT Insuranc # # Ky Fob Insuranc # # Brakdown Rcovry Insuranc # # Motor Insuranc (including fr insuranc supplid with car sals and insuranc purchasd by customrs with rntal cars) # # Othr (Plas spcify): # # # # # # # # Total Incom # # (v) Do you propos to oprat a Clint Prmium Account? (vi) Hav all staff who dal with Insuranc rlatd mattrs rcivd training and ar comptnt to do so? (vii) Will all staff who dal with Insuranc rlatd mattrs mt th IFSRA Training and Comptnc rquirmnts? (viii) Who providd this training and if rquird can you provid a rcord of training rcivd? (ix) Ar any of th principals, partnrs or dirctors awar of any circumstancs, allgations or incidnts which may giv ris to a claim against thir firm or it s prdcssors in businss or any of it s prsnt or formr principals, partnrs, dirctors or mploys? (x) Hav any complaints, circumstancs or claims arisn as a rsult of any fraud or dishonsty of any principals, businss partnr, dirctor or mploy of th proposrs firm/company or if th proposr is a natural prson any such complaints, circumstancs or claims that hav arisn is rlatd to him/hr or thir businss partnrs? If so plas spcify. Sction 8 If intrstd in Dirctors and Offics covr, plas rqust sparat qustionnair. Dirctors and Officrs Liability
Gnral Qustions PLEASE ANSWER FULLY 1 Hav you or any principal in th businss or any company in which you hav had an intrst bn dclard bankrupt, th subjct of bankruptcy procding or mad any agrmnt with crditors? If, giv dtails. DETAILS 2 How long hav you bn stablishd at ths prmiss? If lss than 3 yars, plas provid prvious businss history. YEARS 3 Ar you an NSAI rgistrd firm? if, giv dtails. CLASS OF INSURANCE INSURER 4 Ar you at prsnt insurd or hav you vr proposd for insuranc in rspct of any of th prils or contingncis to which this proposal applis? If, giv dtails. 5 To th bst of your knowldg and blif hav you or any othr prson(s) matrial to this risk a) bn convictd of any driving offnc of any natur or is any proscution pnding or bn disqualifid from driving? b) bn convictd of any offnc of any natur or is any proscution pnding? c) bn rfusd any insuranc, rnwal or had any spcial trms or conditions imposd by an insurr? If to a), b), c) or d) plas giv dtails. d) bn involvd in any accidnt or loss or hav any claims bn mad against you or thm in th past fiv yars? If plas insrt dtails blow. ) bn involvd in any company that has gon into liquidation, bn dclard bankrupt, th subjct of bankruptcy procdings or mad any agrmnt with crditors? if plas giv dtails. (a) Motor Yar Prvious Claims/Accidnt History Total cost of sttld claims Claims not yt sttld Total numbr of accidnt and losss Damag to Third party Damag to Third party proposrs vhicls claims proposrs vhicls claims No. Amount No. Amount No. Amount No. Amount (b) Liability Employrs Public & Products Liability Employrs Liability Claims Public Liability Claims Products Liability Claims Yar Total rmunration to Gross mploys and thr turnovr No. Paid Outstanding No. Paid Outstanding No. Paid Outstanding prson (c) Matrial Damag plus all othr covrs bing proposd for insuranc No. Typ of claim Amount paid Amount outstanding Dat of loss
Additional Information (if any) Dclaration You must tll us any othr facts which ar likly to affct whthr w agr to provid covr, or how w assss th risks proposd for insuranc, including but not limitd to: a) Prvious insuranc claims b) Any convictions, offncs or proscutions pnding of any natur (for xampl, but not limitd to, fraud, thft, pnalty points, driving convictions, or th handling of stoln goods) c) Mdical dtails or history (whn this information is spcifically rqustd undr a sction) and If you ar not sur whthr you should tll us about somthing, plas tll us anyway. This is for your own protction bcaus, if you do not giv us all th information w nd, your policy may not provid you with th covr you nd, a claim may not b paid, th policy may b dclard invalid and void or may b canclld, and you may ncountr difficulty trying to purchas insuranc lswhr. You should also b awar that failur to hav proprty insuranc in plac could lad to a brach of th trms and conditions attaching to any loan scurd on that proprty. Warning: As it is an offnc undr th Road Traffic Act to mak any fals statmnt or withhold information to gt a crtificat of insuranc, you should mak sur that you answr all qustions fully and accuratly. If th proposr is a firm or a privat company, you must rad and answr th qustions as though thy also apply to ach individual partnr or mmbr. Warning: As it is an offnc undr th Road Traffic Act to mak any fals statmnt or withhold information to gt a crtificat of insuranc, you should mak sur that you answr all qustions fully and accuratly. If th proposr is a firm or a privat company, you must rad and answr th qustions as though thy also apply to ach individual partnr or mmbr. Undr th third EU Non-lif Dirctiv w must giv you th following information bfor you buy your policy. Th law that applis to th contract - Undr th rlvant Europan and Irish laws, w Aviva Insuranc Limitd and you, th proposr, ar fr to choos th law that will apply to th contract. W propos that Irish law will apply to th contract. W, Aviva Insuranc Limitd, will provid th insuranc undr this policy. Complaints procdur - W aim to giv xcllnt srvic to all our customrs; howvr, w rcognis that things may occasionally go wrong. W will do our bst to dal with your complaint as ffctivly and quickly as possibl. If you arrangd your covr through an agnt or advisr, plas snd your complaint to thm. If your complaint is not sortd out to your satisfaction, plas contact: Customr Fdback Tam, Aviva Insuranc Limitd, On Park Plac, Hatch Strt, Dublin 2 CallSav: E-mail: Wbsit: 1850 36 37 38 complaints@aviva.i www.aviva.i You can also writ to th Branch Managr - Irland, Aviva Insuranc Limitd, On Park Plac, Hatch Strt, Dublin 2 or you can contact th following Th Irish Insuranc Fdration s Insuranc Information Srvic, 39 Molsworth Strt, Dublin 2 Phon: Fax: E-mail: Wbsit: 01 676 1914 01 676 1943 iis@iif.i www.iif.i Th Financial Srvics Ombudsman Burau, 3 rd Floor, Lincoln Hous, Lincoln Plac, Dublin 2 Phon: LoCall: Fax: E-mail: Wbsit: 01 662 0899 1890 88 20 90 01 662 0890 nquiris@financialombudsman.i www.financialombudsman.i You will not los your right to tak lgal action if you contact ithr of th abov. DATA PROTECTION - Aviva Insuranc Limitd ( w, us or our ), as data controllr, will kp th information you provid about yourslf and about third partis confidntial. W may us it to advis on, provid and administr insuranc products and financial srvics providd by us or othr Aviva companis and somtims with our affiliats and/or commrcial partnrs, in ordr to comply with lgal obligations imposd on us. W may shar th information both insid and outsid of th Europan Economic Ara, in confidnc, for ths purposs with agnts or srvic providrs w hav appointd, privat invstigators, rgulatory organisations, othr insuranc and financial srvics companis (dirctly or via a cntral rgistr), othr Aviva group companis, thos to whom w outsourc crtain businss oprations and as rquird by law. W will procss this information and stor it on our computr and manual rcord systms. To assist in prvnting, dtcting and/or protcting our customrs and ourslvs from thft and fraud, w may us your information to mak sarchs of our or othr Aviva companis rcords. If you giv us fals information or fail to disclos information and w suspct fraud, w will rcord this. W also participat in industry databass such as thos opratd by th Irish Insuranc Fdration for th purpos of sharing of information among insuranc companis as a chck against non-disclosur. From tim to tim, w may rcord your tlphon calls for vrification and training purposs. If you would lik a copy of th dtails w hold about you, plas writ to th Rgulation and Complianc Managr, Aviva Insuranc Limitd, On Park Plac, Hatch Strt, Dublin 2. Plas nclos th corrct f ( 6.35). You also hav th right to corrct any rrors in th information hld about you, block crtain uss or objct to th procssing of your prsonal data. Important: Som of th qustions on this form may ask for dtails about your halth and convictions and th halth and convictions of third partis matrial to this risk plas do not snd us any gntic tst rsults. This information is important for undrwriting and claims purposs and will rmain confidntial. By signing th dclaration blow, you ar giving us prmission to procss ths dtails for th abov purposs, including chcking with third partis or accssing Stat or othr official rcords to vrify whthr th dtails you hav givn ar accurat and complt. By signing blow, you ar confirming that you hav fully xplaind to ach prson who rquirs this insuranc covr why w askd for this information and what w will us it for. You ar also confirming ach prson has agrd to this. ONLY SIGN THE FOLLOWING DECLARATION IF YOU FULLY UNDERSTAND, AND HAVE MET, ALL OF THE ABOVE REQUIREMENTS. Dclaration I/W confirm that, all th dtails, answrs and information givn in this proposal ar tru, accurat and complt. I acknowldg that this proposal will form th basis of my/our contract with Aviva Insuranc Limitd. I/W confirm that I/w am/ar giving my/our prmission to you to us th information I/w hav givn on this form for th purposs st out in th Data Protction sction abov. Your Signatur: Dat: / / W would lik to us your dtails to provid you with information about othr financial or insuranc products, srvics and spcial offrs ithr from us or othr Aviva group companis, or products, srvics and spcial offrs which any mmbr of th Aviva Group may arrang with a third party. Your dtails may also b usd for this purpos (for up to 12 months) aftr your policy has casd. Plas tick hr if you do not wish to rciv such information from us. Your choic will not affct any of th srvics w provid to you, now or in th futur.
Willis Risk Srvics (Irland) Limitd (trading as Willis) is rgulatd by th Cntral Bank of Irland For our joint protction, w may rcord and monitor phon calls. PF.030.11.12c Aviva Insuranc Limitd Aviva Insuranc Limitd, trading as Aviva, is authorisd by th Financial Srvics Authority in th UK and is rgulatd by th Cntral Bank of Irland for conduct of businss ruls. Rgistrd Branch Offic in Irland no. 900175. Rgistrd Branch Addrss On Park Plac, Hatch Strt, Dublin 2. Rgistrd in Scotland No 2116. Rgistrd Offic Pithavlis, Prth, PH2 0NH.