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Wednesday, 19 Jun 2013
Private Vehicle Quote
  1. Full Name(*)
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  2. Date of Birth (dd/mm/yyyy)(*)
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  3. Settlement, Island(*)
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  4. Email(*)
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  5. Telephone(*)
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  6. Place of Employment
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  7. Occupation
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  8. Work Phone
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  9.  
  1. Year, Make & Model of Vehicle
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  2. Type of Body
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  3. C.C/C.I
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  4. Date Purchased (dd/mm/yyyy)
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  5. Price Paid
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  6. Present Value
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  7. Serial Number
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  8. Coverage Required
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  9. Do you own the vehicle and is it registered in your name? If no, give details.(*)
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  11. Is the loan in your name? If not, whose name is it in?(*)
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  13. Do you have any non-motor insurance with us? If yes, give details.(*)
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  15. For what purpose will the vehicle be used?
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  16. If vehicle will be used primarily on an island other than New Providence, state name of island.
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  17.  
  1. Does your vehicle have any existing body damages? If yes, give details.ence, state name of island.
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  2. Has the vehicle ever been in an accident or declared a Total Loss or Salvage?
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  4. Give the following details of all persons likely to drive (including Proposer):
  5. Name, Relationship, Date of Birth, Occupation/Place of Employment, Year License Obtained, License Number (Hit Enter/Return ONLY when entering another driver.)
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  7. Has the vehicle been modified or fitted with oversized tires or a high performance engine or equipment?
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  8. Have you, or to the best of your knowledge, any person likely to drive the vehicle(s) or has any Motor Vehicle under your control or belonging to you been involved in any accidents during the last five years?
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  9. Have you or any person likely to drive held a full licence for less than two years?
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  10. Have you or any person likely to drive been charged with a motoring offence?
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  11. Will anyone under the age of 25 be driving?
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  12. Do you or any operator suffer from any physical impairment or medical condition?
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  13. Has any company during the past five years, declined, cancelled, refused to renew or imposed conditions or an excess for you or any other person likely to drive?
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  14. If you have answered “YES” to any of the questions, give details below.
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  15.  
  1. Do you have or have your ever held a Motor Vehicle Insurance Policy?
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  2. If so, state name of insurance company, type of insurance coverage, and period coverage held.
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  3. Are you entitled to a No Claim Discount? (You will be required to provide proof.)
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  4. Name
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  5. Date
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  6.  
  1. I/we hereby warrant the truth of the above statements, and I/we have withheld no information whatever which might tend in any way to increase the risk of the Company or influence the acceptance of the proposal. I/We agree that this Proposal shall be the basis of the Contract between me/us and J.S. Johnson & Company Ltd, and I/we further agree to accept a Policy subject to its conditions, to pay the premium thereon and warrant that the vehicle(s) is/are and shall be kept in good repair and condition. I /we further declare and agree that if the above quote form was completed by any person other than the undersigned such person shall be deemed to have been my/our Agent for the purpose of filling in this Proposal Form. I/we undertake that the vehicle(s) to be insured shall not be driven by any person who to my/our knowledge has been refused any Motor Vehicle insurance or continuance thereof. I/we further undertake immediately to disclose to the Company any alterations affecting the truth of the answers given above.
  2. By selecting the submit button you agree to this statement.
  4. Rates will be quoted on receipt of the above particulars. The company reserves the right to decline any proposal. No liability is accepted by the Company until the issue of the Policy and the payment of the premium, or the issue of a duly authorised Cover-Note.
  5. Date (dd/mm/yyyy)
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