MOTOR POLICY PROPOSAL FORM Policy Period From: To: DETAILS OF PROPOSER Name of Proposer* I.D. Card No.* Date of Birth Email* Address of the proposer Occupation Telephone No. VAT Reg. Number (if applicable) DETAILS OF MOTOR VEHICLE Particulars of Motor Vehicle to be insured Registration No. Make & Model Year of Make Date of Purchase Engine No. Type of Body Number of Passengers Price Paid Chassis No. Engine Capacity Colour Fuel Estimate of present value including accessories and spare parts 7. Is the vehicle usually kept overnight (a) in a locked garage? (b) in the open but on your premises? (c) elsewhere? 8. Has the vehicle been modified to give an increased performance from the makers’ published specification, or is it intended to do so? Yes If YES please give details No 9. How long have you (a) been regularly driving a vehicle? (b) held a motor vehicle full driving licence? 10. Authorized Drivers Details of Driver * One Driver 25 years and over Two Driver 25 years and over Any Driver 25 years and over Any Driver 25 years and over and specified drivers over 21 Any Driver 25 years and over and specified drivers over 18 Specified Drivers Under 25 Years Name of Driver(s) Date of Birth Driving Experience 11. Do you, or does any other person who to your knowledge will drive, suffer from defective vision or hearing or from any physical or mental infirmity or disease? Yes If YES please give details No 12. Have you, or has any other person who to your knowledge will drive, been convicted during the past 5 years of any offence with a motor vehicle? Yes If YES please give details No 13. Are you the owner of the vehicle and is it registered in your name? Yes No If NO state name and address of (a) the owner (b) the person in whose name the vehicle is registered Is any finance company interested in the vehicle? Yes No If YES give name and address Name Address Was the Vehicle purchased outside Malta? Yes No If Yes state Country 14. Will the vehicle be used (a) solely for social, domestic and pleasure purposes? (b) for carriage of passengers or goods for hire or reward or any other purposes for which you receive payment? (c) for the purpose of your own or your employer’s business? (d) for any other business purpose? If YES please give details 15. Will the vehicle be used in competitions, rallies or trials? Yes No If YES give full particulars 16. Have you been or are you now insured in respect of any motor vehicle? Yes No If YES please state the name and address of insurer and policy number Name Address Policy number 17. How many years “No Claim Discount” are you entitled to? years Please attach renewal notice from insurer 18. Have any additional drivers been driving for less than 24 months? Yes No If YES give details 19. Has any insurer ever (a) declined your proposal? Yes No (b) required you to bear the first part of any loss? Yes No (c) required an increased premium or imposed special conditions? Yes No (d) cancelled or refused to renew your policy? Yes No If YES give full particulars 20. Have any accidents, losses or damages (whether covered by insurance or not) occurred during the past four years in connection with any motor vehicle owned, driven or used by you ? Yes No If YES give full particulars Year No Cost (paid or estimated) Nature of payment (e.g. own damage, third party etc.) Brief details of the incident 21. Please tick the cover required Third Party Only Third Party, Fire and Theft Comprehensive 22. If a comprehensive policy is required do you wish to (a) increase the first amount of each claim for loss or damage to your vehicle ? Yes No If YES please state the amount (Lm50 / Euro 116.47) (Lm100 / Euro232.94) any such ‘excess’ is ADDITIONAL to any compulsory excess which is incorporated in the policy (b) opt for the Protected No Claim Discount scheme? Yes No (c) opt for the Earthquake extension? 23. Do you have other current motor policies or home policies with Middlesea Insurance p.l.c.? Yes No If YES please give Policy Number(s) Confirm you have read and agree to the data protection policy
