PROPOSER'S INFORMATION VEHICLE(S)DETAILS COVER REQUIRED DRIVER APPLICATION FORM ACCIDENT DETAILS
MOTOR INSURANCE PROPOSAL FORM 01
VEHICLE OWNERSHIP, CONDITION AND USE
View Application
Do you own the vehicle(s)?
Yes No

Is it/Are they registered in your name?

 Yes No
Title No.

Details of the registered owner if other than the proposer
   Name
   Address
   Occupation

Is the vehicle the subject of a loan?
Yes No

Loan Information
   Name
   Address

Is the vehicle roadworthy and in good condition?		 Yes No

Are there any other vehicles insured in your name?		 Yes No
  If so,state Insurer and Policy No.
Is the vehicle specially fitted with a Radio, Cassette, CD or other accessories? Yes No
  If so, are they to be specifically insured? Yes No
  Estimated Value(s)
$
Has the vehicle been tuned, converted, altered or otherwise modified in any way? Yes No

  If so, give full details of modification

Will anyone to your knowledge be using the vehicle to learn to drive? 		Yes No

Will anyone under 21 or over 70 years be allowed to drive? 		Yes No

Is/Are there any anti-theft devices attached?
Yes No
  If so, state type
Where and how will the vehicle be secured overnight/when not in use?
Carport
Private driveway
Private garage
Public road/street
Guarded lot
Other
In addition to private and pleasure, will the vehicle be used for
The carriage of own goods
Professional and Bussiness purposes such as sales and the like
The carriage of goods for others
The carriage of passengers for payment(hire or reward)
Any other purpose
  If any other purpose specify
State type of goods being carried (if applicable)
 

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