Auto Coverage

Year, Make & Model of Vehicle*
Type of Body*
C.C/C.I*
Date Purchased

Date Format: DD slash MM slash YYYY
Price Paid
Present Value*
Serial Number
Coverage Required*
- Comprehensive
- Third Party
- Third Party Fire & Theft
Do you own the vehicle and is it registered in your name?*
- Yes
- No
If no, give details.
Is the loan in your name?
- Yes
- No
If not, whose name is it in?
Do you have any non-motor insurance with us?
- Yes
- No
If yes, give details.
For what purpose will the vehicle be used?*
If vehicle will be used primarily on an island other than New Providence, state name of island.*

Do you have or have your ever held a Motor Vehicle Insurance Policy?*
- Yes
- No
Coverage Started*
Coverage Ended*
If so, state name of insurance company, type of insurance coverage, and period coverage held.
Are you entitled to a No Claim Discount? (You will be required to provide proof.)
- Yes
- No
Agreement & Submit

I declare to the best of my knowledge and belief the information on this form is true in every respect. I also declare that if anything on this form was written by another person, he or she acted as my agent for this purpose. I agree to keep the property in a good state of repair during the currency of this Insurance. I agree that this proposal and declaration will be the basis of the contract between me and the Insurer.

By selecting the submit button you agree to this statement.
Name

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

Agreement & Submit