12.
If you wish to cover accessories give details and values
Stereo / DVD Player Roof Rack Spot/Fog lamps Others (Please specify)
13. Give details of Trailer or
Side car if attached
14. State fully for which purpose the vehicle Private Commercial Other(Please specify )
is going to be used:
15. Whom will be the vehicle Self Self & Spouse Paid Driver Other (Please specify )
be driven by?
16. Normally who drives the vehicle?
17. Will the vehicle be driven by anyone under the age of 25?
YES NO
(There is an extra excess in the policy for young and inexperienced drivers)
18. Do you wish to cover the additional risks of:
YES NO
Earthquake.
Flood, Cyclone.
Riot and Strike
19. Are you insuring the vehicle for duty free value? (For all duty free vehicles, in case of partial
damages the condition of average would apply)
20. Do you wish to waive the condition of Average for Partial damages by additional payment of premium?
YES NO
21. Do you or any other person to your knowledge will drive the vehicle suffer from defective vision (not corrected by glasses)
YES NO
or hearing (not corrected by hearing aid) and/or physical disability and/or chronic disease or illness?
If yes give full details.
22. Have you or any other person to your knowledge who will drive the vehicle:
YES NO
(a) Been convicted during the past five years facing prosecution for a motoring offence?
(b) Not been driving a vehicle for the last five years due to suspension of license?
(c) Been any time refused Motor vehicle insurance or refused renewal or imposed with
special terms or higher premium
(d) During the last five years been involved in any accident irrespective of blame or cause?
23. Is a Finance company or any other party financially interested in the vehicle?
YES NO
If yes, please give details.
24. Do you own or use any other vehicle?
YES NO
If yes, please give details along with name of insurers.
25. Do you have any other insurance with Jubilee Insurance?
YES NO
If yes please give details
26. Are you eligible for a No Claim Discount?
YES NO
Please provide proof:
27. Please give details of claims/ accidents in the last five years on your Vehicles as under:
Year No. of vehicles Paid Claims Outstanding claims Total Amount not covered
by insurance
No. Amount No. Amount No. Amount
28. Are there any additional circumstances or facts affecting the proposed insurance that should be disclosed to the Company for their consideration of this insurance?
If YES, give full details
Date At Signature of the Proposer
IMPORTANT NOTE
1. Specimen copy of the Policy Form and other terms applicable to risk is available, on request by the Proposer.
2. Please note that the above is for your general information only. For further details and specific information, please refer to the Policy whose terms and
conditions, exceptions, clauses and warranties are applicable to this insurance.
3. The Policy holder shall keep a record of all information including copies of letters supplied to the insurers for the purpose of entering into the contract.
A copy of the completed Proposal Form will be supplied to the Proposer on request after its completion
