It is important that you answer all questions with great care and that your answers are full, accurate
and truthful. This requirement applies throughout the life of the contract and not just at inception. A
failure to do this could lead to the policy being voided and claims not being paid. If you’re in any
doubts then it’s best to disclose the information and I can let you know if it’s likely to be deemed
material.
Any personal information that you provide to us will be used in accordance with our Privacy Policy
and for purposes of providing our services; Please click
HERE for a copy of our Privacy Policy.
Name of Proposer
Full Postal Address
Post Code
Email
Contact Telephone
Employment status
Occupation
Nature of Business
Trading As
How long have you been in business?
If you have ever traded in another name, please give details
Registration/ Chassis Number
Make/ Model
Cubic Capacity
Year of Manufacture
Gross Vehicle Weight
Cover
Date of Purchase
Seats
Where is the vehicle kept overnight?
Post code where kept overnight
Value
Type of Body
Expected Annual Mileage
Vehicle Keeper
Vehicle Owner
Any changes from manufacturers' standard specification?
Any Security Devices, other than manufacturer standard equipment?
Driver Restrictions
Authorised Drivers
Main Driver
Use Required
Give details of yourself and any other person who may drive (especially those under 25 years of age)
Name of Driver
Date of Birth
Occupation
Type of (UK or EU) full or provisional licence
Year test passed for vehicle proposed
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years +
How long driven regulalry in the UK?
Have you had an insurance policy declined or any special terms imposed?
Details:
Driving Qualifications provided by AA Drive Tech
Date Recieved
Convictions
Motor Conviction(s) Details
Non-Motor Convictions
Non-Motor Conviction(s) Details
Accidents / Claims / Losses
Accidents/Claims/Losses Details
Details of Additional Driver No.1
Additional Driver No.1
Date of Birth
Occupation
Type of (UK or EU) full or provisional licence
Year test passed for vehicle proposed
How long driven regulalry in the UK?
Has Additional Driver No.1 had an insurance policy declined or any special terms imposed?
Details:
Driving Qualifications provided by AA Drive Tech
Date Recieved
Convictions
Motor Conviction(s) Details
Non-Motor Convictions
Non-Motor Conviction(s) Details
Accidents / Claims / Losses
Accidents/Claims/Losses Details
Name of Previous Insurer
Policy Number
Expiry Date
No Claims Bonus Entitlement
Any Additional Information?
Data Protection Notice
Please read this notice carefully as it contains important information about the details you will have given us. It is a condition of this insurance that you read and accept the terms of this data protection notice. You should show this notice to anyone covered by this insurance. We will process the details you have provided in line with Data Protection Act 1998 and other laws which may apply. Your information may also be processed outside of the European area. In all instances we make sure that your information has enough protection. So that we can assess the terms of an insurance contract, or deal with any claims that may arise, we may need to share information which is classed as 'sensitive' under the Data Protection Act 1998. We may pass this information to other organisations that we have carefully chosen as well as other companies within our group. We share information with other insurers, certain government organisations and other authorised for the purpose of insurance underwriting, preventing or detecting fraud, managing claims and managing complaints. If you have any questions please contact the Company Secretary at ERS, 52 - 54 Leadenhall Street, London, EC3A 2BJ. By proceeding with this application you signify your consent to such information being processed in this way.
Important Notes
1. WARNING: If you provide false or incorrect information or withhold information, your policy can be cancelled or declared void. We may also refuse to pay a claim. You should keep a complete record of all information supplied to the underwriters for the purpose of entering into this contract of insurance (including copies of all letters).
2. At your request a copy of this completed form will be supplied to you, provided the request is made within a period of three months after its completion.
3. Underwriters liability does not operate until acceptance has been notified or a Cover Note delivered to the insured. If the proposal should disclose any special features the underwriters may quote special terms and they reserve the right to decline a proposal.
4. Details of full policy terms will be supplied on request.
Important Notes
Information about your insurance policy will be added to the Motor Insurance Database (MID) which is managed by the Motor Insurers' Bureau (MIB). Certain government or authorised organisations including the police, the DVLA, the DVLNI, the Insurance Fraud Bureau and other organisations allowed by law may use the MID and the information stored on it for the purposes including Continuous Insurance Enforcement (you can get information about this from the Department of Transport), electronic vehicle licensing, law enforcement for the purposes of preventing, detecting, catching and prosecuting offenders and providing government services or oher services aimed at reducing the level of uninsured driving. If you are involved in a road-traffic accident (either in the UK, the EEA or certain other territories), insurers or the MIB (or both) may search the MID to gather relevent information. Anyone making a claim for a road-traffic accident (including their appointed representatives and citizens of other countries) may also gather relevant information which is held on the MID. It is vital that the MID holds your correct registration number. If it is ot shown correctly on the MID, you are at risk of having your vehicle seized by the police. You can check that your correct registration number details are shown on the MID at www.askmid.com.
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