75 Front Street, Hamilton HM 12 - Phone: +1 441 2963600 - Fax: +1 441 2956209 - E-mail: email@example.com - Mailing Address: P.O. Box HM 836, Hamilton HM CX, Bermuda
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Proposal to Insurers for insurance of a Private Motor Car
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.
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.
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