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Home Insurance Proposal Form
First Name
*
Last name
*
Birthday
*
Day
Month
Year
Email
*
Phone
*
Work Phone
*
Address
*
Occupation
*
Employer
*
Island/Settlement
*
Year driver's license obtained
*
Make and model of Vehicle
*
Year
*
Engine Size
*
Body Type
*
Date Purchased
*
Day
Month
Year
Serial Number (VIN)
*
Price Paid
*
Was the vehicle duty free?
*
Yes
No
What will the vehicle be used for?
*
On which island will the vehicle be used primarily?
*
Coverage Sought
*
Comprehensive (Maximum vehicle age: 8 years)
Third Party Fire & Theft (Maximum vehicle age: 5 years)
Third Party
Do you own the vehicle?
*
Yes
No
If not, please provide name and contact details of registered owner
*
If the car has a loan, please provide the name on the loan
*
Will anyone under the age of 25 be driving the vehicle?
*
Yes
No
If yes, please provide date of birth
*
Day
Month
Year
Has the vehicle been modified or fitted with oversized tires or hight performance engine or equipment?
*
Yes
No
Has the vehicle ever been in an accident or declared a Total Loss or Salvage
*
Yes
No
Please provide details of any existing vehicle damage
*
Have you or anyone likely to drive the vehicle:
*
Held a full driver's license for less than 2 years?
*
Yes
No
Been involved in any accident during the last 5 years, whether it was your fault or not?
*
If YES, please provide details of accident
*
Have you filed an insurance claim within the past 2 years?
*
Yes
No
If YES, please provide details
*
Been charged with a motoring offense?
*
Yes
No
Suffer from any physical or medical condition
*
Yes
No
If YES, please provide details
*
Please provide the following information for all persons likely to drive the vehicle: name, relationship to proposer, date of birth, occupation/place of employment, years drivers license obtained
*
Submit
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