CarCover Form - Freisenbruch

Basic information

Proposer’s Full Name*

First Middle Last

Postal Address*

Postal Code*

Primary Contact Number

Telephone Number (Business)

Email*

Occupation and Nature of Duties*

(including any part time or casual)

Insurance Required from*

Insurance Required to*

Is the Motor Car the subject of a Loan agreement?*

If so, with who?

How did you hear about Freisenbruch?

What cover do you require?*

Comprehensive

Third Party Fire and Theft

Third Party Only

Increased Deductible*

Premium discounts may be available to Proposers age 26 or over who select Comprehensive cover. If you are willing to bear an increased deductible from our standard, please select alternative deductible of either $500, $750 or $1,000.

None

$500

$750

$1000

Are you entitled to a no claim discount?*

Yes

Renewal Notice*

Attach your latest Renewal Notice or a letter from your previous Insurer confirming the number of claim-free years.

Accepted file types: pdf, jpg, jpeg, png, bmp, Max. file size: 8 MB.

Do you require no claim discount protection?*

Only available if you select Comprehensive and you are entitled to 60% NCD. An extra premium will be charged for this.

Yes

About your motor car and how it will be used

Make*

Model*

Year*

Engine Capacity*

Registration Number*

Date of Purchase

Estimated Value*

(inc. accessories)

Engine number*

Chassis number*

Is the car owned by or registered in the name of another person?*

Yes

Has the car been altered/modified from the maker’s specification?*

Yes

For what purpose will the car be used?*

Please check all appropriate boxes

Social, domestic and pleasure

By you for your business

By your spouse for his/her business

By any other person for their business

By any other person for HIRE or REWARD

For any other purpose

Usage details

Provide any additional details about the usage of your vehicle here.

Comprehensive / Third Party Fire & Theft Details

If you selected comprehensive or third party fire & theft coverage would you like us to automatically decrease the sum insured of your vehicle by 10% at each renewal?*

Yes

Accessory Value

The policy covers permanently fitted accessories designed for audio or visual entertainment or for communication purposes (e.g. radios, cassette players, in-car telephones) but is subject to a limit of $1,000 in total for all these items. If you require a higher limit than $1,000 please state the amount of additional cover you require. An extra premium will be charged for this.

Drivers

Who will drive?*

Use the plus button on the right to add additional rows. Note: license type should be listed as appears on your Bermuda Driver's License (1. Private Car; 2. Motorcycle less than or equal to 150ccs; 2A. Auxiliary cycle less than or equal to 50ccs; 3. Light truck and private car; 4. Intermediate light truck and private car; 5. Tractor; 6. Construction machine; 7. Ambulance; 8. Fire engine)

Full Name

Years of Driving Experience

Date of Birth (DD/MM/YYYY)

Occupation

Date Passed Bermuda Driving Test (DD/MM/YYYY)

Type of Bermuda Licence Held

Main User? (Yes/No)

About the Drivers

Have YOU or ANY PERSON who will drive:

A) Been involved in any vehicle accident or loss in the last five years? (Date, Type, Amount of loss if known)*

This includes all vehicle accidents/losses/thefts irrespective of blame and whether or not an insurance claim resulted

Yes

B) Been convicted of any motoring offence (other than parking) during the last 5 years or is any prosecution pending?*

(Date, Type - including speed, penalty)

Yes

C) Been refused motor insurance or been quoted an increased premium or had special terms imposed?*

Yes

D) Been convicted of any offence for dishonesty of any kind or is any such prosecution pending?*

Yes

E) Been disqualified from driving?*

(Date, period of disqualification)

Yes

F) Suffered from any physical or mental ailment or infirmity that would cause you/they to be unfit to drive and that is not adequately controlled to your/their doctor's satisfaction?*

We may request a declaration of your/their fitness to drive. Please do not provide specific medical/health details for privacy reasons.

Yes

Additional driver information

If you have answered Yes to any of questions A through E above, please give details in the space provided for additional information below.

Declaration

Please read the following carefully and then sign and date the Declaration

IMPORTANT – the answers you have given to these questions will usually provide us with sufficient information to enable us to consider this Proposal. However, because a list of questions cannot be exhaustive, please consider carefully whether there is any other information known to you that could influence our acceptance and assessment of the risk. Material information would include any special feature of the vehicle, use or driver’s history which make losses more likely to happen or more serious if they do. Please disclose to us on a separate sheet of paper any such information even if you have doubts as to whether it is material or not, as failure to do so could invalidate your policy. You should also keep your own record (including copies of letters) of all information supplied to us in arranging this insurance. Before signing the Declaration, please check your answers particularly if this Proposal Form is not completed in your own hand.

Declaration

I declare that to the best of my knowledge and belief, the answers above are true and all material information as explained above has been disclosed. I agree that if any answer had been written by any other person, such person shall for that purpose be regarded as my agent and not the agent for the Insurers. I agree that this Proposal is for insurance under the normal terms and conditions of the Insurer’s policy and shall be incorporated in and form the basis of the insurance contract.

Signature

Date

This field is for validation purposes and should be left unchanged.